Point Prevalence Survey of Healthcare-Associated ... · trained IPC staff member, that person was an infection prevention and control nurse (IPCN) (93.5%). However, for the majority

HALT 2016 Ireland National Report 1

Point Prevalence Survey of Healthcare-Associated Infections & Antimicrobial Use in Long-Term Care Facilities (HALT): May 2016

IRELAND: NATIONAL REPORT – MARCH 2017

Report Authors: Sarah Hennessy, Helen Murphy & Karen Burns, HPSC

SUGGESTED CITATION: HEALTH PROTECTION SURVEILLANCE CENTRE, POINT PREVALENCE

SURVEY OF HEALTHCARE-ASSOCIATED INFECTIONS & ANTIMICROBIAL USE IN LONG-TERM

CARE FACILITIES: MAY 2016 – IRELAND NATIONAL REPORT: MARCH 2017


Table of Contents Acknowledgements .......................................................................................................... 3

Executive Summary .......................................................................................................... 4

Priorities for Implementation ........................................................................................... 8

Plain Language Summary ............................................................................................. 1-18

1. INTRODUCTION ....................................................................................................... 21

2. METHODS ................................................................................................................ 22

3. HALT 2016 RESULTS ................................................................................................. 25

3.1 NATIONAL OVERVIEW ............................................................................................. 25

Description of Participating LTCF .................................................................................................. 25

Governance Structures ................................................................................................................. 27

3.2 HCAI ................................................................................................................. 40

MICROBIOLOGY RESULTS – PATHOGENS & ANTIMICROBIAL RESISTANCE ............................................ 45

4. PREVIOUS HALT SURVEYS ........................................................................................ 55

LTCF-ACQUIRED INFECTION (LAI): 2010 - 2016 ........................................................................ 55

ANTIMICROBIAL USE: 2010 - 2016 ......................................................................................... 57

5. DISCUSSION ............................................................................................................. 61

6. REFERENCES ............................................................................................................ 75

7. APPENDICES ............................................................................................................ 78

APPENDIX A: LIST OF HALT 2016 PARTICIPATING LTCF ............................................................... 78

HSE-OWNED LTCF, STRATIFIED BY CHO AND BY CARE TYPE ........................................................... 85

APPENDIX B: HALT 2016 NATIONAL STEERING GROUP MEMBERSHIP ............................................. 86

APPENDIX C: ACRONYMS USED IN THIS REPORT ........................................................................... 87

APPENDIX D: HALT RESIDENT QUESTIONNAIRE & HCAI DEFINITIONS .............................................. 90

APPENDIX E: COMMUNITY HEALTHCARE ORGANISATIONS (CHO) MAP OF IRELAND ............................. 94


Acknowledgements

All of the HALT 2016 participating facilities are listed in Appendix A

The members of the HALT Steering Group (Appendix B) would like to sincerely acknowledge the

commitment of all healthcare staff who volunteered to participate and those who supported the

2016 HALT survey:

Local HALT coordinators

Local HALT data collectors

Long-term care facility nursing staff who assisted with completion of ward lists and resident

questionnaires

Long-term care facility directors of nursing and management staff

Infection prevention and control nursing staff who assisted with data collection

Clinicians and general practitioners who assisted with data collection

Community and long-term care facility pharmacy staff who assisted with data collection

Staff of the facility who volunteered as the HALT data validation site

Dr Nuala O’Connor, ICGP Lead for HCAI & AMR & member of HALT 2016 Steering Group

Ms Mary Wynne, Interim Nursing & Midwifery Services Director, HSE

Ms Deirdre Mulligan, Interim Area Director, Nursing & Midwifery Planning & Development,

HSE

Dr Darina O’Flanagan, Director HPSC (Retired May 2016)

Dr Kevin Kelleher, Assistant National Director, Health & Wellbeing – Health Protection, HSE

Dr Philip Crowley, HSE National Director, Quality Improvement Division

Ms Katrien Latour, HALT European Coordinating Team, Scientific Institute for Public Health

(WIV-ISP), Brussels, Belgium

Ms Béatrice Jans, HALT European Coordinating Team, Scientific Institute for Public Health

(WIV-ISP), Brussels, Belgium (Retired November 2016)

Dr Carl Suetens, Senior Expert Antimicrobial Resistance & Healthcare-Associated Infections,

European Centre for Disease Prevention & Control, Stockholm, Sweden


Executive Summary

In May 2016, 10,044 residents in 224 Irish long-term care facilities (LTCF) were included in a

European point prevalence survey (PPS) of healthcare-associated infections (HCAI) and antimicrobial

use. The survey is also known as the HALT survey. This is the national report for Ireland.

Aims of the HALT survey

1. To calculate the prevalence of HCAI in residents of Irish LTCF

2. To calculate the prevalence of and indications for antimicrobial use in Irish LTCF

3. To provide the Irish Government, Department of Health, Health Service Executive (HSE), the

managers, doctors and nurses caring for residents in all of the participating LTCF with

information for action: to reduce the numbers of residents who develop HCAI and to

influence positive antimicrobial stewardship practices in LTCF

4. To provide residents, their families, friends, carers and members of the public with more

information about HCAI in Ireland and which types of infections are most commonly seen in

Irish LTCF

Participating LTCF

Of the 224 LTCF, the majority were owned by the HSE [n=136; 61%], followed by private

[n=54; 24%] and voluntary services [n=34; 15%]

The median capacity of participating LTCF was 42 beds (range = 5 – 176) and the median

bed occupancy on the HALT survey date was 93%

Overall, single room accommodation accounted for a median of 71% of available beds.

The proportion of single room accommodation in HSE-owned (52%) was lower than that

of private (83%) and voluntary (87%) LTCF

For the purposes of data analysis and reporting, the HALT steering group stratified the

224 LTCF into the following care type categories, based on the characteristics and

estimated length-of-stay (LOS) for the majority of the residents:

i. General nursing homes >12 months (GN>12m): 88 long-stay facilities with 4,722

residents

ii. Mixed care type facilities >12 months (Mixed>12m): 46 long-stay facilities with

2,499 residents


iii. LTCF caring for residents with intellectual disabilities (Intellectually disabled): 31

long-stay facilities with 1,251 residents

iv. LTCF (either general nursing homes or mixed care type facilities) <12 months

(LTCF<12m): 14 short-stay facilities with 441 residents

v. LTCF caring for residents with psychiatric conditions (Psychiatric): 23 long-stay

facilities with 505 residents

vi. Other care types: Facilities caring for residents with palliative care needs (seven

long-stay facilities with 134 residents), rehabilitation needs (five long-stay facilities

with 245 residents), physical disabilities (one long-stay facilities with 13 residents)

and ‘other’ care types (nine long-stay facilities with 234 residents)

Nurse and healthcare assistant staffing, medical care and coordination, infection prevention &

control & antimicrobial stewardship

For the first time, HALT 2016 collected information on nurse and healthcare assistant

staffing ratios per 100 LTCF beds, with differences observed based on LTCF ownership and

LTCF care type. The observed staffing ratios do not necessarily reflect the national picture

for multiple reasons and additional information which directly influences staffing levels was

not collected (e.g., resident dependency and comorbidities)

Overall, resident medical care was provided by the resident’s own general practitioner (GP)

in 49.5%, by a directly-employed doctor in 28.5% and by a mix of GP plus directly-employed

doctor care in 22% of LTCF. However, when LTCF were stratified by ownership, GP-led

medical care was 96% in private LTCF versus 33% in HSE LTCF

A designated coordinating physician, with responsibility for coordination and standardisation

of policies/practices for resident medical care within the LTCF was available for 65% of LTCF

overall and for 56% of private LTCF

An active local infection prevention and control committee (IPCC) was reported by 61% of

LTCF

Access to a staff member with infection prevention and control (IPC) training was reported

by 76% of LTCF overall and by 57% of private LTCF. For the vast majority of LTCF with a

trained IPC staff member, that person was an infection prevention and control nurse (IPCN)

(93.5%). However, for the majority of LTCF (58%), the IPCN was not based in the LTCF on a

day-to-day basis

A written local hand hygiene policy was available in 95% of LTCF, with provision of a staff

hand hygiene training session in the past 12 months reported by 83% of LTCF. The available


products for hand hygiene were alcohol-based hand rub (ABHR) and liquid soap in 96% and

95% of LTCF, respectively

Compliance with hand hygiene opportunities was not collected in HALT 2016

The provision of seasonal influenza vaccination for residents was not universal, with 9% of

LTCF overall reporting this was not routine local practice

The vast majority (98%) reported having no active local antimicrobial stewardship

committee (ASC), training on antimicrobial prescribing was not provided by 94% and 56% of

LTCF reported having no local antimicrobial prescribing guidelines

Prescriber feedback regarding local antimicrobial consumption was available in just 14% of

LTCF

LTCF with a designated coordinating physician were significantly more likely to demonstrate

positive local antimicrobial stewardship practices such as; an active ASC, training for

prescribers and local prescribing guidelines

Resident demographics, nursing care requirements and HCAI risk factors

Female residents predominated in most care types, other than psychiatric and palliative

LTCF. The proportion of residents aged ≥85 years was highest in GN>12m (49%), Mixed>12m

(47%) and LTCF<12m (41%). In contrast, 1% of intellectually disabled LTCF residents were

aged ≥ 85 years

Selected indicators of resident nursing care requirements (incontinence, disorientation and

impaired mobility) were evident in all care types, but most prevalent in GN>12m,

Mixed>12m and LTCF<12m

HCAI risk factors (presence of urinary or vascular catheter, pressure sores or ‘other’ wounds)

were most prevalent in palliative care LTCF

Almost two percent (n=170) of residents with an infection or taking antimicrobials, had a

history of hospitalisation within three months of the survey

LTCF-acquired infections (LAI)

For infections acquired in long-term care, the national crude prevalence was 4.4% and the

median prevalence was 3.4%. The median prevalence was higher in LTCF<12m (6.6%),

rehabilitation (4.9%) and mixed>12m (4.5%). The highest prevalence was reported in

palliative care LTCF (8.3%), which may reflect underlying illness and the prevalence of HCAI

risk factors encountered in that unique resident cohort


The most prevalent LAI types were: respiratory tract infections (RTI), urinary tract infections

(UTI) and skin infections; affecting 1.5%, 1.5% and 1.1% of all residents, respectively

A relevant microbiological specimen had been obtained for 37% of infections, with

microorganisms isolated in 14%. Escherichia coli (35%) and Staphylococcus aureus (29%)

were the most frequently reported microorganisms. Of those with available antimicrobial

susceptibility results, 4% of E. coli were resistant to 3rd generation cephalosporins and 16%

of S. aureus were meticillin/flucloxacillin resistant (i.e., MRSA). There were no LAI associated

with carbapenem resistant Enterobacteriaceae (CRE) reported during the HALT survey

Hospital-acquired infections (HAI)

For the first time, HALT 2016 collected data on hospital-acquired infections (HAI), whereby

the resident was transferred to the LTCF with an active HAI or developed a HAI on day one

or day two following transfer to the LTCF. No HAI were reported by 88% of LTCF. The crude

national prevalence of HAI in Irish LTCF was 0.4%. Therefore, the vast majority of HCAI in

LTCF in Ireland are acquired within the LTCF

Antimicrobial use and antimicrobial resistance

The national crude antimicrobial use prevalence was 9.8%, with a median antimicrobial use

prevalence of 8.3%. The median prevalence was higher in LTCF<12m (12.1%) and

rehabilitation LTCF (10.9%). At 30.8%, the prevalence in palliative care LTCF was more similar

to that reported in acute hospitals

The majority of antimicrobials were prescribed within the LTCF (83%)

Overall, 59% of antimicrobials were prescribed to treat infection. However, antimicrobial

prophylaxis accounted for the majority of prescriptions in intellectually disabled LTCF (54%)

During HALT 2016, 3.4% of Mixed>12m and 3.1% of GN>12m residents were prescribed

antimicrobials for UTI prophylaxis. Prophylaxis against RTI was most prevalent in

intellectually disabled (2.0%) and palliative care (1.5%) LTCF


Priorities for Implementation

There have been four HALT surveys conducted in Ireland since 2010. The findings of the most recent

survey in May 2016 demonstrates that HCAI and antimicrobial use remain prevalent issues in Irish

LTCF, regardless of the LTCF care type. The annual increase in LTCF participating in HALT is a positive

finding, with 96 LTCF performing their first HALT survey in 2016 and 39 having participated in all four

HALT surveys to date. There is now evidence that participation in repeated HALT surveys has

impacted positively on the prevalence of infection and antimicrobial use in 2016 for the 39 LTCF that

have completed all four HALT surveys, as shown in Figure 4.1.5. However, many Irish LTCF have yet

to undertake a HALT survey and participation in surveillance alone is not enough to drive sustained

improvement. The findings of the HALT surveys to date and the recommended priorities now need

to be implemented.

The existing gaps in resourcing have become acutely evident, in the context of a rapidly increasing

national incidence of antimicrobial resistant bacteria, such as multi-drug resistant Klebsiella

pneumoniae (MDRKP) and carbapenem resistant Enterobacteriaceae (CRE), with cases and

outbreaks in Irish LTCF reported. For HSE-owned LTCF, the development of an Accountability

Framework for Quality & Safety within the Social Care Division is welcomed and has potential to

drive the implementation of many of the recommendations for HSE Social Care Division within this

HALT report. However, the delivery of residential care in Ireland is not limited to services provided

by the HSE and antimicrobial resistant bacteria will not respect boundaries of services providers.

Therefore, it is vitally important that implementation of the recommended priorities and investment

in resources ensures that residents in all Irish LTCF, regardless of care type and ownership have

equitable access to the specialist input of multi-disciplinary infection prevention and control and

antimicrobial stewardship teams and geriatricians with community input and that regional HCAI &

antimicrobial resistance (AMR) Committees are established in each community healthcare

organisation (CHO), with membership, governance and oversight including all LTCF, regardless of

ownership.

The recommended priorities for implementation arising from the findings of HALT 2016 are outlined

in the following tables. For each theme, the column describing ‘who is involved’ in delivering on

implementation is not intended to restrict participation and will require more in-depth discussion to

attribute ownership on publication of this report. Within the tables, LTCF management team refers

to all LTCF, regardless of care type or ownership.


Theme Priority Who is involved? Timeline Comment

Standards Adaptation of key principles of HIQA National Standards for PCHCAI*, including antimicrobial stewardship activities within each LTCF

Revised Standards expected 2017

LTCF management team Short term HIQA & Mental Health Commission (MHC) PCHCAI & antimicrobial stewardship Standards specific to these care settings are needed

Licensing & Regulation Require all LTCF to demonstrate evidence of compliance with key principles of PCHCAI standards as part of monitoring inspection for licensing

HIQA

MHC

LTCF management team

Short tem HIQA & Mental Health Commission (MHC) PCHCAI & antimicrobial stewardship Standards specific to these care settings are needed

Governance Develop multi-disciplinary regional HCAI & AMR Committees to provide governance, oversight, guidance of HCAI prevention, surveillance and antimicrobial stewardship within each CHO**

HSE Social Care Division

Departments of Public Health

Private and voluntary LTC providers

ICGP

Microbiology laboratories

IPU – Community pharmacy

Short term Membership, terms of reference, reporting relationships and action plans need to be developed and define to guide regional committee structures and ensure similar delivery of service across each CHO

Governance Regardless of geographical boundaries of acute hospital groups and CHOs, each LTCF should have established active lines of communication with the acute hospital(s) to and from which the residents are transferred, the microbiology laboratory which processes resident specimens and the local Department of Public Health

LTCF management, nursing and physician team

Acute hospital management, clinician and nursing teams

Microbiology laboratory

Department of Public Health

Short term

Organisation Review existing geography, whereby acute hospital group catchment areas, public health regions and CHOs are not currently aligned

Department of Health


HSE Health & Wellbeing Division


Medium term Realignment is needed

*HIQA PCHCAI = Health Information & Quality Authority National Standards for Prevention & Control of Healthcare-Associated Infections (2009)



LTCF staffing Ensure that every LTCF has nurse staffing levels that reflect the number and case mix of residents in the facility

Ensure that every LTCF has healthcare assistant staffing levels that reflect the number and case mix of residents in the facility

Ensure that the skill mix of nursing and healthcare assistants appropriate for the needs of the residents



HSE Clinical Programmes

NMBI


LTCF management teams

HIQA

MHC

Short term Gap analysis, workforce planning are required

Need to define acceptable staffing standards within different care types

LTCF staffing Ensure every LTCF has a nominated coordinating physician, with evidence of this to be sought as part of monitoring inspection for licensing



Private & voluntary LTC providers

ICGP

Regional HCAI & AMR Committees

HIQA & MHC

Short term Definition of recommended elements of coordinating physician job description that are of relevance to HCAI prevention and antimicrobial stewardship is needed

LTCF staffing Develop the IPC link nurse/practitioner role within each LTCF in each CHO




Short term – For LTCF without a designated on-site IPCN, ensure every LTCF has a nominated IPC link nurse and a nominated community IPCN with whom they can liaise

Curriculum, educational and training needs and assessment materials need to be developed to progress these roles



CHO IPC & stewardship team staffing

Progress appointment of community IPCNs within each CHO

Specialist advice should be available for every LTCF within each CHO, regardless of care type or ownership






Short term – Ensure every CHO has access to at least one IPCN

Medium term – Build IPCN team resources and ensure that within every CHO, the recommended IPCN resource for 1.0 WTE per 250 LTCF beds is achieved

Gap analysis, workforce planning, definition of the job description and multi-disciplinary team building are integral to ensuring development of a sustainable, proactive and responsive community IPCN workforce


Ensure every CHO has designated Antimicrobial Pharmacist with dedicated sessions to provide specialist input

Specialist advice should be available for every LTCF within each CHO, regardless of care type or ownership


HSE Clinical Programme


Short term Workforce planning, definition of the job description and multi-disciplinary team building are integral to ensuring development of a sustainable, proactive and responsive community antimicrobial stewardship workforce


Ensure every CHO has a designated Consultant Microbiologist with dedicated sessions to provide specialist input

HSE Social Care & Acute Hospitals Divisions on basis that consultant appointment likely to be shared between acute and community setting



Short term Definition of the recommended elements of the job description of a Consultant Microbiologist post with community remit is needed


Ensure every CHO has a designated Consultant Geriatrician with dedicated sessions to provide specialist input

Specialist advice should be available for every older person LTCF within each CHO, regardless of ownership

HSE Social Care & Acute Hospitals Divisions on basis that consultant appointment likely to be shared between acute and community setting



Short term Definition of the recommended elements of the job description of a Consultant Geriatrician post with community remit is needed



Education for LTCF staff Standard & transmission-based precautions, IPC risk assessment, device management, key messages about antimicrobial resistant bacteria, HCAI prevention, diagnosis, treatment and management, antimicrobial stewardship


HSE Clinical Programmes & Advisory Groups

HPSC

Short term Curriculum, educational and training needs and assessment materials need to be developed

Link training to CPD credits

Education for GPs Standard & transmission-based precautions, IPC risk assessment, device management, key messages about antimicrobial resistant bacteria, HCAI prevention, diagnosis, treatment and management, antimicrobial stewardship

ICGP



HPSC

Short term Curriculum, educational and training needs and assessment materials need to be developed

Link training to CPD credits

Education for LTCF residents, their families, friends and carers

Development of user-friendly information materials on key messages


HPSC

HSE Communications


Patient representative organisations

Short term Information leaflets

Information videos

Dedicated website

Residents stories



Communication Develop and implement a national interfacility transfer document template to ensure systematic communication of known or suspected transmissible pathogens (influenza, norovirus, C. difficile ifnection) and multi-drug resistant organisms (CRE/CPE, ESBLs, VRE, MRSA etc.) when residents are transferred between healthcare settings



NMBI

HPSC


Short term

Seasonal influenza vaccination of healthcare workers

Staff seasonal influenza vaccine uptake should be an annual KPI, with targets within every CHO





HPSC


Short term Peer vaccinator programmes require roll-out

Educational materials specific to the LTCF setting need to be developed

Seasonal influenza vaccination of residents

Resident seasonal influenza vaccine uptake should be an annual KPI, with targets within every CHO



HPSC


Short term


Theme Priority Who is involved Timeline Comment

Guidelines Require all LTCF to demonstrate evidence of implementation of the elements of existing national antimicrobial prescribing guidelines for primary care

HIQA

MHC



HPSC analysis of HALT PPS results

ICGP

CPD audit performed by prescribers

Short term www.antibioticprescribing.ie

Guidelines Require all LTCF to demonstrate evidence of implementation of the elements of existing national guidelines relevant to urinary tract infection (UTI),

Diagnosis and management of UTI in LTCF residents >65 years (2011)

Prevention of catheter-associated UTI (2011)

HIQA

MHC



Short term Review and update of the guidelines are required

Guidelines Require all LTCF to demonstrate evidence of implementation of the elements of existing national guidelines for prevention and control of antimicrobial resistant bacteria that apply to the particular healthcare setting

MRSA

MDRO other than MRSA (ESBLs, CRE/CPE, VRE etc.

HIQA

MHC




Short term Review and update of the guidelines are required

Guidelines Require all LTCF to demonstrate evidence of implementation of the elements of existing national guidelines for C. difficile that apply to the healthcare setting

HIQA

MHC




Short term Review and update of the guidelines as required

http://www.antibioticprescribing.ie/


Theme Priority Who is involved Timeline Comment

Guidelines Require all LTCF to demonstrate evidence of implementation of the elements of existing national guidelines prevention and management of influenza outbreaks in residential care facilities

HIQA

MHC




Short term Review and update of the guidelines as required

Guidelines A national guideline should be developed on urinary tract infection prophylaxis


HPSC

ICGP

Microbiology, nephrology, urology representation

Short term UTI prophylaxis

Lack of evidence to support practice

Costs money

Driver for antimicrobial resistance

Driver for C. difficile infection risk

Loss of the agent for future treatment

Side effects of prolonged courses



Surveillance Evidence of participation in HALT surveys should be sought as part of monitoring inspection for licensing

HIQA

MHC

Short term

Surveillance Participation in future HALT surveys should be required and specified in service level agreements for service provision between HSE and non-HSE LTC providers




HPSC

Medium term HSE Social Care Division should review HALT 2016 participant list, identify and follow up with LTCF that did not undertake the survey in 2016 to identify barriers to participation and promote future participation

Surveillance Develop prospective HCAI incidence surveillance programmes of relevance to LTCF settings

HPSC


Medium term Protocol development, training, IT-based user-friendly surveillance process, with timely feedback and reports are integral to this process

Surveillance Develop prospective antimicrobial prescribing surveillance programmes of relevance to LTCF settings

HPSC

ICGP


Irish Pharmaceutical Union (IPU)

HSE ICT Division

Medium term Protocol development, training, IT-based user-friendly surveillance process, with timely feedback and reports are integral to this process

Surveillance

Develop regional antimicrobial resistance surveillance reporting template for key pathogens against first line treaments and key indicator agents (3

rd generation

cephalosporins and carbapenems for Enterobaceriaceae, flucloxacilin for S. aureus


Microbiology laboratories

MEDLIS project team

HPSC


Medium term Potential examples for inclusion:

E. coli & K. pneumoniae in urines from LTCF residents (MSU vs CSU)

S. aureus in swabs from LTCF residents

C. difficile positive faeces from LTCF residents

Lack of geographical alignment of acute hospitals group microbiology laboratories and CHOs hinders provision of meaningful data



Key performance indicators (KPIs)

Develop meaningful KPIs for LTCF

Template for every KPI needs to be developed to ensure staff know how and when to collect the data, how to report the data and how to interpret the data

Same methodology to be used in every LTCF within each CHO

Start with KPIs that demonstrate evidence that staff have received key training for HCAI prevention and antimicrobial stewardship

%

Progress to KPIs that demonstrate implementation of HCAI prevention & antimicrobial stewardship measures

$

Ensure a system for monitoring KPIs



NMBI

HPSC



Short term%

Medium term$

%

Hand hygiene – practical, e-learning

Standard precautions – practical, e-learning

Transmission-based precautions – practical, e-learning

IPC risk assessment

Influenza prevention education session

$

Hand hygiene compliance

Urinary catheter management

Rates of antimicrobial use

% of residents prescribed antimicrobial prophylaxis

Quality Improvement Develop systems whereby findings of surveillance are used to inform quality improvement priorities within CHOs and individual LTCFs


HPSC



Medium term

PPS of HCAI and Antimicrobial Use in LTCF (HALT), 2016 HPSC

Plain Language Summary 18

Plain Language Summary

Background

During May 2016, 224 Irish long-term care facilities (LTCF) took part in a European survey known as

the HALT survey. It was coordinated in Ireland by the Health Protection Surveillance Centre (HPSC).

The HPSC is the national centre for the surveillance of infections in Ireland. An invitation to

participate in the HALT survey has been extended to all European Union countries.

During April 2016, staff members from the LTCF went to a training day, where they were taught how

to perform the survey. The survey was then carried out in each LTCF, using the same set of

instructions. Once the survey was completed, the results from each LTCF were collected and

checked at the HPSC. The results have been put together to produce this national report for Ireland.

The results for every LTCF that took part have also been returned to each individual LTCF, so they

can be used to help the staff to make future plans to further improve resident care.

The HALT survey was done for the following reasons:

1. To count the number of residents with an infection, which may have occurred as a result of

healthcare: so-called ‘healthcare associated infection’ or HCAI for short

2. To count the number of residents who were prescribed antibiotics

3. To provide the Irish Government, Department of Health, Health Service Executive, the

managers, doctors and nurses in all of the LTCF that took part, with information about HCAI

and antibiotic prescribing in Irish LTCF in 2016 and to compare progress since the HALT

survey was last undertaken in Ireland in 2013. This information is important to plan future

ways to reduce the numbers of residents who get HCAI and to reduce the chance that

antibiotics may be prescribed unnecessarily

4. To provide residents, their families, friends, carers and members of the public with more

information about HCAI in Ireland and which types of infections are most commonly seen in

Irish LTCF

The count of the residents with a HCAI and the residents prescribed antibiotics is called ‘prevalence’.

These results provide us with a picture or a snapshot of the number of residents with a HCAI and the

number of residents prescribed antimicrobials in the Irish LTCF that took part in the HALT survey in

May 2016.

In this report, each of the participating LTCF has been categorised into commonly encountered care

types, based on the typical characteristics and length-of-stay for the majority of residents in the

LTCF: The most common LTCF care types in Ireland are: general nursing homes (long-stay), mixed



care type LTCF (long-stay), LTCF where the majority of residents stay for less than 12 months (short-

stay), intellectually disabled LTCF, psychiatric LTCF, rehabilitation LTCF and palliative care LTCF.

Long-term care facility-acquired infections

These are infections that developed more than two days after a resident was admitted to the LTCF.

Such infections are important because they can cause harm to residents. Not every infection can be

prevented from happening, but every opportunity should be taken to prevent infection, whenever

possible.

In Ireland, there were 10,044 residents counted in 224 LTCF. Of those, 441 had a LTCF-acquired

infection at the time of the survey. This means that 4.4% or just under one-in-twenty residents

present in Irish LTCF in May 2016 had a LTCF-acquired infection. However, because different LTCF

may care for different types of residents, it is not possible to directly compare the results of one

LTCF with those of another LTCF.

The most common types of infections reported in the survey were as follows:

1. Respiratory tract infections, which may include chest infections and pneumonia

2. Urinary tract infections, which may include infections of the bladder or kidneys

3. Skin or wound infections

In this survey, it was found that residents who had an infection were more likely to have some of the

common ‘risk factors’. Well-known risk factors for developing infection can include: having had a

recent operation, having a drip or a bladder catheter and being older. Three LTCF residents were

reported to have acquired Clostridium difficile infection during the HALT survey.

Antibiotic use

Antibiotics are extremely important to treat infection caused by bacteria. There is concern around

the world that bacteria are becoming more and more resistant to antibiotics, so they no longer work

to treat common infections. This problem is made worse by the fact that there have been very few

new types of antibiotics developed to overcome this problem of resistance. It is very important that

antibiotics are only used when they are absolutely necessary and that they are not used in the

incorrect circumstances, such as to try and treat infections caused by viruses. It is also very

important that antibiotics are not used for too long and that the course of treatment is kept as short

as possible.

This survey found that of the 10,044 residents who were counted, 981 were prescribed antibiotics.

This means that 9.8% or about one-in-ten residents present in Irish LTCF in May 2016 were taking an



antibiotic. However, because different LTCF may care for different types of residents, it is not

possible to directly compare the results of one LTCF with those of another LTCF.

This survey shows that antibiotic prescribing is common in Irish LTCF. Most residents were

prescribed antibiotics to treat infection. However, a proportion of residents were prescribed

antibiotics to prevent infection, which is also known as prophylaxis. Most antibiotic prophylaxis was

prescribed to prevent urinary tract infection. The results of the survey show that it is very important

to make sure that antibiotic prescribing in LTCF is done properly and that antibiotics are prescribed

appropriately. This in turn, will reduce the chances of antibiotic resistant bacteria becoming

commonplace in Irish LTCF, reduce the risk of residents picking up Clostridium difficile infection and

preserve the use of antibiotics for treatment of infection in residents in the future.


Introduction 21

1. Introduction

This report outlines the findings of the fourth national survey conducted in May 2016 to assess the

prevalence of HCAI and antimicrobial prescribing practices in Irish LTCF. Irish LTCF first participated

in a European-wide PPS of HCAI in long-term care facilites (HALT) in 2010. (1-3) In 2011, Ireland

repeated a national HALT survey. (4) The third HALT survey in Ireland and the second European HALT

survey took place during May 2013. (5-6)


Methods 22

2. Methods

The HALT survey in Europe is coordinated by the European Centre for Disease Prevention & Control

(ECDC) and the Scientific Institute of Public Health (WIV-ISP), Brussels, Belgium. The HALT survey in

Ireland is coordinated by the Health Protection Surveillance Centre (HPSC) and was overseen by a

multi-disciplinary steering group convened in January 2016, under the auspices of the Royal College

of Physicians of Ireland (RCPI) Clinical Advisory Group on HCAI & AMR (Appendix B). The steering

group met on four occasions between January and October 2016 to plan for the HALT survey and the

report of its findings.

In January 2016, an invitation to participate in HALT was extended to LTCF by HPSC. Participation

was voluntary. However, at least one person from each participating LTCF was required to attend a

training day. During April 2016, 214 healthcare workers attended one of six regional training days to

learn about the survey protocol and methodology. The schedule of presentations for each training

day included; an introduction to HALT survey methodology, presentations and practical case studies

to enable trainees to practice completion of the HALT data collection forms (Appendix D). All

training materials were posted on the HALT section of the HPSC website. A dedicated HALT e-mail

address was established to address any queries from participants. A frequently-asked questions

section was also maintained on the HPSC website. Information leaflets were prepared for residents

and their families, friends or carers, for LTCF staff and General Practitioners (GPs).

The survey was conducted using a standard protocol devised by the European HALT Coordinating

Team. The European HALT protocol was adapted for use in Ireland. All study documentation related

to HALT 2016, including protocol and data collection forms were posted on a dedicated HALT section

of the HPSC website:

http://www.hpsc.ie/hpsc/A-

Z/MicrobiologyAntimicrobialResistance/InfectionControlandHAI/Surveillance/HCAIinlongtermcarefa

cilities/

During the HALT survey, all eligible residents in each LTCF were surveyed by a local HALT team for

anonymous demographic details, risk factors, antimicrobial use and the presence of an active HCAI.

HCAI were defined using standardised infection definitions. The McGeer criteria for defining HCAI in

LTCF were published in 1991. (7) They have not been formally validated. In 2009, the Society for

Healthcare Epidemiology of America (SHEA) and the US Centers for Disease Control & Prevention

http://www.hpsc.ie/hpsc/A-Z/MicrobiologyAntimicrobialResistance/InfectionControlandHAI/Surveillance/HCAIinlongtermcarefacilities/




Methods 23

(CDC) convened a multi-disciplinary group to update the McGeer criteria by systematic review of

literature. (8) Most studies evaluated were small observational or uncontrolled case series and

evidence was generally judged to be of low quality. Therefore, grading of evidence was not done and

the updated criteria require validation in different types of LTCF. The revised criteria incorporate

changes to surveillance definitions of UTI and RTI and added new categories for norovirus

gastroenteritis and Clostridium difficile infection (CDI). (8)

Similar to previous HALT surveys performed in 2010, 2011 and 2013, participants in HALT 2016 were

required to record all relevant signs and symptoms on a resident questionnaire. For HALT 2010 and

2011, the McGeer criteria were adapted to include the criterion ‘physician diagnosis’. In earlier HALT

surveys, the HALT software analysed recorded signs and symptoms and reported the presence or

absence of a HCAI according to the McGeer criteria. However, in 2013 and 2016, participants were

required to follow algorithms on the resident questionnaire and decide for themselves whether a

HCAI was present or absent using the revised CDC/SHEA definitions. (Appendix D – Resident

Questionnaire).

For the first time in 2016, the HALT survey also collected information on hospital-acquired infections

(HAI), whereby a resident returned from the hospital to complete their HAI treatment course in the

LTCF or developed signs and symptoms meeting surveillance criteria for infection on day one or day

two following transfer to the LTCF. As a HAI, surgical site infection (SSI) was added as a separate

infection type to the HALT 2016 protocol. Specific definitions for timing of infection acquisition were

also utilised for CDI and SSI.

For the purposes of this report, healthcare-associated infections (HCAI) are subdivided into two

separate categories:

1. Long-term care facility (LTCF)-acquired infections (LAI) – Collected in all HALT surveys to date

2. Hospital-acquired infections (HAI) – Collected in HALT 2016 only

In prior HALT surveys, whenever an antimicrobial was prescribed, information was sought regarding

whether or not a relevant microbiological sample had been taken from the resident prior to starting

the antimicrobial. In HALT 2016, the protocol changed, whereby information on microbiology

samples was sought only on residents who fulfilled a HCAI surveillance definition. Therefore, the

microbiology findings from 2016 are not comparable with those of previous HALT surveys.

A local HALT report was issued by HPSC to each of the 224 participating LTCF by November 2016.


Methods 24

Data Management & Analysis

Data were collected on paper forms (Appendix D) and subsequently entered electronically to a

downloadable software application. The completed data file was returned electronically from each

participating LTCF to HPSC.

The complete dataset from Ireland was also returned to the HALT European Coordinating Team for

inclusion in the European HALT analysis and report, which is expected to be published in 2018.

Data was analysed using Microsoft Access and Excel. Statistical analysis were carried out using

STATA/SE v11.2 and OpenEpi v3.01. ArcView GIS v3.2 was used for data mapping.

Data Validation

Ireland also contributed HALT data to a European validation study. This was designed to validate the

HALT data collection across Europe. During May 2016, two members of the HALT national

coordinating team visited one LTCF and conducted a parallel HALT survey. The anonymous data

collected simultaneously by the local HALT team and the validation team were returned for inclusion

in the European HALT validation analysis and report.

Of 224 LTCF, 35 (16%) reported that a local physician had been involved in validating the data

collected on residents who were prescribed antimicrobials and/or who had signs or symptoms

suggestive of an active HCAI.


Results National Overview 25

3. HALT 2016 Results

3.1 National Overview

Description of Participating LTCF

There was an excellent response to participate in the voluntary 2016 HALT survey, with a continued

increase in participating LTCF; from 69 (2010), 108 (2011), 190 (2013) to 224 (2016), as displayed in

Table 3.1.1. There has also been an annual increase in participating LTCF across care types (Table

3.1.1), although fewer general nursing homes participated in 2016 than in previous years. Thirty-nine

LTCF have participated in all four HALT surveys to date, 64 have participated in the last three surveys

(2011, 2013 and 2016), 119 have participated in the last two surveys (2013 and 2016), with 96 (43%)

participating in HALT for the first time in 2016.

In Ireland, HSE-funded community health services are geographically distributed into Community

Healthcare Organisations (CHOs). For the first three HALT surveys in Ireland (2010, 2011 & 2013),

HSE-owned LTCF were stratified by HSE region, which have been replaced by CHOs since 2014. For

comparison, Table 3.1.1 displays the HSE owned LTCF annual participation by HSE region and Figure

3.1.1 displays the percentage of HSE-owned LTCF by CHO that participated in HALT 2016.

Table 3.1.1 Annual increases in HALT participation, by ownership, HSE region and care type.

* Nine LTCF self-selected the ‘Other care type’ category in 2016, indicating their resident case mix did not fit in the more common LTCF

categories. These included: Mixed care type LTCF (n=5), young chronically ill unit (n=2), dementia specific facility (n=1) and a low

dependency residential unit (n=1).

Category 2010 2011 2013 2016

by Ownership

HSE 61 84 128 136

South 8 18 38 45

West 32 34 42 46

Dublin Mid Leinster 14 22 23 20

Dublin North East 7 10 25 25

Private 8 24 39 54

Voluntary n/a n/a 23 34

by Care Type

General nursing homes 30 58 103 88

Mixed care facilities 16 16 26 46

LTCF <12 month stay n/a n/a 15 14

Intellectually disabled 8 15 24 31

Psychiatric 3 5 11 23

Palliative care 1 1 4 7

Physically disabled 1 1 2 1

Rehabilitation 1 1 3 5

Other 3 1 2 9

National 69 108 190 224



Refer to Appendix E for the CHO map of Ireland.

Figure 3.1.1. HSE-owned LTCF by CHO that participated in HALT 2016.

LTCF were categorised into eight major care types, as displayed in Table 3.1.2.

General nursing homes with estimated LOS >12 months (long-stay) = GN>12m

Mixed care type facilities with estimated LOS >12 months (long-stay) = Mixed >12m

LTCF (either general nursing homes or mixed care type facilities) with estimated LOS <12

months (short-stay) = LTCF <12m

LTCF caring for residents with intellectual disabilities (Intellectually disabled)

LTCF caring for residents with psychiatric conditions (Psychiatric)

LTCF caring for residents with physical disabilities (Physically disabled)

LTCF caring for residents for intensive rehabilitation (Rehabilitation)

LTCF caring for residents with palliative care needs (Palliative care)

Other care types: Nine LTCF self-selected the ‘Other’ category in 2016, indicating their

resident case mix did not fit in the more common LTCF categories. These included: Mixed

care type LTCF (n=5), young chronically ill unit (n=2), dementia specific facility (n=1) and a

low dependency residential unit (n=1)



Table 3.1.2 also displays further breakdown of each care type, by ownership, bed numbers, overall

bed occupancy and proportion of single rooms. Overall, there was a median of 42 beds (range = 5 -

176 beds) per LTCF, with 59 beds in privately-owned, 51 beds in voluntary and 33 beds in HSE-owned

LTCF.

Overall, the median bed occupancy was 93%, with a median single room availability of 71%. While

HSE-owned facilities tended to have fewer beds, there were differences in single room availability

based on ownership, with single rooms less common in HSE-owned (52%), than LTCF under private

(83%) and voluntary (87%) ownership.

Table 3.1.2 Breakdown of participating LTCF, by ownership and care type.

Governance Structures

Provision of Nursing & Medical Care

Availability of 24-hour qualified nursing care is a prerequisite for participation in the HALT survey.

For the first time, the HALT 2016 survey collected data on the total number of whole time equivalent

(WTE) registered nurses (excluded pre-registration student nurses) and WTE healthcare assistants

(HCA) working in each LTCF, with the ratio expressed per 100 LTCF beds. Caution is required in

interpretation of these results, as they represent staffing levels in LTCF that participated in HALT

2016 and do not necessarily reflect the staffing levels within all LTCF in Ireland.

Category No. of LTCF

Total

residents

Surveyed

Median

proportion

of single

rooms

Median

percentage

of beds

occupied

n median min max n % %

by Ownership

HSE 136 33 5 167 5213 52 91

Private 54 59 19 140 3031 83 95

Voluntary 34 51 10 176 1800 87 94

by Care Type

General nursing >12 months 88 55 18 167 4722 73 98

Mixed >12 months 46 50 20 142 2499 61 91

LTCF <12 months 14 35 16 72 441 52 87

Intellectually disabled 31 28 5 176 1251 92 96

Psychiatric 23 22 10 86 505 57 86

Palliative care 7 19 8 48 134 80 79

Physically disabled 1 14 14 14 13 100 93

Rehabilitation 5 64 14 72 245 44 90

Other 9 27 13 60 234 53 85

National 224 42 5 176 10044 71 93

Size of facility



Differences in nurse staffing ratios were more evident than HCA staffing ratios, when LTCF were

stratified by ownership, as displayed in Table 3.1.3. Voluntary-owned LTCF had a mean WTE nursing

staff to 100 beds ratio of 61.6, versus 55.2 for HSE-owned and 19.3 for privately-owned LTCFs. The

differences in nurse staff:bed ratios by ownership may reflect differences in the types of residents

and resident dependency levels. While selected nursing care load indicator information was

collected, such as incontinence, disorientation and impaired mobility, in-depth information on

resident dependency and co-morbidity was not collected and would be integral to further

interpretation of staffing:bed ratios. Within the most common LTCF care types that had participation

of >10 LTCF, differences in WTE nursing staff to 100 beds ratios were evident, with higher nurse

staffing levels in LTCF caring for residents with psychiatric and intellectual disabilities. HCA staffing to

bed ratios were similar between the nursing home-type LTCF, higher in intellectually disabled LTCF

and lower in psychiatric LTCF.

Table 3.1.3 Ratios of WTE nursing staff and HCA per 100 beds, by ownership and care type.

Care type categories with <10 LTCF were excluded from this analysis

For HSE-owned LTCF participating in HALT 2016, further analysis of WTE nurse and HCA staffing

levels by CHO and by care type within each CHO was not carried out, in view of a wide range in

participation of HSE-owned LTCF by CHO (n= 5 – 38), coupled with variance in numbers of individual

care types within each CHO (n= 1 – 41).

A variety of models of medical care exist in Irish LTCF, as displayed in Figure 3.1.2. Care was provided

by the resident’s own GP in 49%, a directly-employed doctor in 29% and in the remaining 22%, a

mixed care model was observed, with both GPs and directly-employed doctors providing medical

care.

Mean Min Max Mean Min Max

by Ownership

HSE 136 5213 55.2 5.0 270.0 51.1 0.0 200.0

Private 54 3031 19.3 3.6 41.4 47.7 16.1 72.6

Voluntary 34 1800 61.6 15.2 126.3 63.3 20.3 220.0

by Care Type

General nursing >12 months 88 4722 32.2 8.1 77.6 50.9 29.1 102.5

Mixed >12 months 46 2499 36.7 3.6 63.5 50.6 10.8 103.7

LTCF <12 months 14 441 44.2 24.1 65.0 46.0 19.0 91.4

Intellectually disabled 31 1251 71.1 32.5 108.3 87.0 0.0 220.0

Psychiatric 23 505 77.4 24.0 270.0 19.1 0.0 82.6

National 224 10044 47.6 3.6 270.0 52.2 0.0 220.0

WTE Nurses per 100 beds WTE HCA per 100 bedsCategory

No. of

LTCF (n)

No.

Eligible

Residents



Differences were also observed based on LTCF ownership. While the vast majority of privately-

owned LTCF opted for the GP-led model of care (96%), a more heterogenous model of care (GP only,

directly employed medical staff only or a mixture of the two) was evident for HSE and voluntary-

owned LTCF.

Figure 3.1.2 Models of medical care provision in LTCF, by ownership type and CHO (for HSE-owned

facilities)

Regional differences were also observed within HSE-owned LTCF, as displayed in Figure 3.1.3.

Figure 3.1.3 Proportion of GP-led care in LTCF, by CHO.



The medical care model also varied by LTCF care type, as displayed in Figure 3.1.4. GPs provided the

majority of medical care in GN>12 (67%) and intellectually disabled LTCF (52%). Medical care in

palliative care and rehabilitation LTCF was more likely to be provided by directly-employed medical

staff.

Figure 3.1.4 Models of medical care provision in LTCF, by care type.

Coordination of Medical Care

Participants were asked to provide information regarding the coordination of medical care within

the facility. This was defined as having a designated ‘coordinating physician’ to arrange medical

activities and take responsibility for standardisation of practices/policies for resident care. Figure

3.1.5 displays the coordination of medical care.

Overall, 35% reported having no coordinating physician. For the 65% with a coordinating physician, a

variety of models of coordination were delivered; external (38%), internal (19%) or a mixture of both

(8%). Privately-owned LTCF were more likely to report having no coordinating physician (44%). For

those that had a coordinating physician, the vast majority provided external coordination, which

correlates with the predominantly GP-led medical care model observed in private LTCF.



Figure 3.1.5 Coordination of medical care, by LTCF ownership.

Differences in coordination of medical care were also observed when facilities were stratified by

care type (Figure 3.1.6). Absence of a coordinating physician was commoner in intellectually disabled

LTCF (42%) and GN>12 (39%), whereas a coordinating physician was present in the majority of

palliative care LTCF (86%).

Figure 3.1.6 Coordination of medical care, by care type.



Infection Prevention & Control (IPC) Practices

Table 3.1.4 displays the IPC structures, educational practices and protocols. Further description of

these categories is provided subsequently.

Table 3.1.4 Overview of IPC structures, education and protocols, by ownership and care type.

Staff with Training in IPC & Access to Advice from External IPC Experts

Overall, 170 (76%) LTCF reported access to a staff member with IPC training. HSE LTCF or voluntary

LTCF were more likely to have access to staff with IPC training (83% and 76%, respectively) than

private LTCF (57%).

Of 170 LTCF with access to an IPC-trained staff member, 99 (58%) reported that person was not

based within the LTCF on a day-to-day basis, 48 (28%) reported that person was based within the

LTCF on an ongoing basis and 23 (14%) reported that person attended the LTCF on a sessional basis.

Where a staff member with IPC training was available, for the majority of LTCF, that person was a

nurse (n=159; 93.5%). Ten LTCF (6%) reported having both a nurse and a doctor with IPC training and

one LTCF (0.5%) reported having a doctor with IPC training.

Staf

f with

IPC

trai

ning

Expe

rt IP

C ad

vice

IPC

com

mitt

ee

Han

d hy

gien

e tr

aini

ng

IPC

trai

ning

of n

ursin

g/pa

ram

edic

al st

aff

IPC

trai

ning

of G

Ps/m

edic

al st

aff

MRS

A

Han

d hy

gien

e

Man

agem

ent o

f urin

ary

cath

eter

s

Man

gem

ent o

f vas

cula

r cat

hete

rs

Man

gem

ent o

f ent

eral

feed

ing

by Ownership type

Private (n = 54) 57 72 35 81 81 11 89 89 87 37 83

Voluntary (n = 34) 76 68 56 88 88 44 94 97 94 50 85

HSE (n=136) 83 83 73 83 88 14 97 97 88 49 83

by Care Type

GN > 12 months (n = 88) 70 81 53 84 82 9 91 90 89 40 84

Private only (n = 40) 58 73 38 80 75 10 85 85 83 25 80

Voluntary only ( n = 7) 71 100 43 71 86 43 100 86 86 43 71

HSE only (n = 41) 83 85 71 90 88 2 95 95 95 54 90

Mixed > 12 months (n = 46) 76 89 63 85 85 15 100 100 98 43 93

Intellectually disabled (n = 31) 87 71 65 84 94 16 90 97 90 39 84

LTCFs < 12 months (n = 14) 86 85 57 86 86 36 100 100 100 71 93

Psychiatric (n = 23) 61 65 70 74 87 35 96 96 52 39 48

Palliative care (n = 7) 100 43 71 86 100 57 100 100 100 86 71

Physically Disabled (n =1) 100 0 100 0 100 0 100 100 100 100 100

Rehabilitation (n = 5) 100 60 100 80 100 20 100 100 100 100 100

National 76 78 61 83 86 18 95 95 89 46 83

IPC Protocols

% % %

IPC EducationIPC Structure



In addition to having access to staff with IPC training, information was sought on access to external

expert IPC advice (e.g., from the local hospital or Department of Public Health). Overall, 175 LTCF

(78%) reported having access to such advice, with no access reported by 49 LTCF (22%). Access to

expert IPC advice was less common in psychiatric LTCF (65%), rehabilitation LTCF (60%) and palliative

care LTCF (43%).

Infection Prevention and Control Committee (IPCC)

An active local IPCC was reported by 137 (61%) LTCF, with a median of three meetings per year

(range = 0 - 12). Private GN >12 (38%), voluntary GN >12 (43%) and LTCF <12 months (57%) were less

likely to have an IPCC.

Staff Training

Overall, provision of IPC training was available in the majority of LTCF (86%) for nursing and

paramedical staff, but in the minority of LTCF (18%) for medical staff. Private LTCF offered less access

to staff IPC training for nursing, paramedical and medical staff. Medical staff were more likely to

receive IPC training if they worked in a voluntary-owned LTCF (44%) or a palliative care LTCF (57%).

Hand Hygiene Training

Overall, 83% reported that a staff hand hygiene training session had been organised during the

previous year (2015). This figure was higher in voluntary LTCF (88%) and HSE GN>12 (90%). Hand

hygiene training was lower in psychiatric LTCF (74%) and voluntary GN>12 (71%).

Seventy-three percent of LTCFs reported completing hand hygiene training in 2014 and 66%

reported hand hygiene training in both 2014 and 2015.

Access to Hand Hygiene Products

The HALT protocol did not specify whether data on hand hygiene product availability applied to staff

use only or whether resident hand hygiene products could be included.The vast majority of LTCF

reported having alcohol-based hand rub (ABHR) (96%) and liquid soap (95%) as available hand

hygiene products (Table 3.1.5). Alcohol-based wipes were reported to be available in 41% of LTCF,

ABHR was reported as the preferred hand hygiene method in 68%. Data on the estimated volume of

ABHR consumed during the previous year (2015) was provided by 78% of LTCF, reporting an average

consumption of 145 litres. Hand washing with a non-antiseptic soap was the preferred method in

20% and hand washing with antiseptic soap in 8% of LTCF.



Observation of Hand Hygiene Opportunities

For the first time, HALT 2016 collected data on observation of hand hygiene opportunities within

individual LTCF during the previous year (2015). Data on compliance with hand hygiene

opportunities was not collected. However, 51% of LTCF reported that formal audit of staff hand

hygiene compliance was carried out in the previous year (2015).

Table 3.1.5 Availability of hand hygiene products, preferred hand hygiene methods and observed opportunities.

Availability of Written Protocols

Information regarding the availability of written protocols for staff on the following topics was

sought (Table 3.1.4):

Management of MRSA and other multi-drug resistant organisms (MDRO): Available in 95%

overall, with lower rates reported from intellectually disabled LTCF (90%) and private GN>12

(85%)

Hand hygiene: Available in 95% overall, with lower rates reported from voluntary GN>12

(86%) and private GN>12 (85%)

Management of urinary catheters: Available in 89% overall, with lower rates reported from

private GN>12 (83%) and psychiatric LTCF (52%)

Hand hygiene products/methods

Product

Alcohol rub

Liquid soap

Wipes

Bar soap

Preferred Method

Hand disinfection with an alcohol solution

Hand washing with water and a non antiseptic soap

Hand washing with water and an antiseptic soap

Unanswered

Observed hand hygiene opportunities

0

1-100

>100-499

>500

Hand hygiene audit 2015

Yes

No

% of LTCFs

96

95

41

8

4

56

1

68

20

36

5

3

51

33



Management of vascular catheters: Available in 46% overall, with lower rates reported from

intellectually disabled and psychiatric LTCF (both 39%) and private GN>12 (25%)

Management of enteral feeding: Available in 83% overall, with lower rates reported from

voluntary GN>12 and palliative care LTCF (both 71%) and psychiatric LTCF (48%)

Table 3.1.6 displays the surveillance and additional IPC activities. Further description of these

categories is provided subsequently.

Table 3.1.6 Overview of surveillance and general IPC activities, by ownership and care type.

MDROs: Multi-drug resistant organisms

HC

AI s

urv

eilla

nce

Per

form

ing

aud

its

on

IPC

po

licie

s an

d p

roce

du

res

Feed

bac

k o

f su

rvei

llan

ce r

esu

lts

to s

taff

Mo

nit

ori

ng

inci

den

ce o

f M

DR

Os

Off

erin

g in

flu

enza

imm

un

isat

ion

to

res

iden

ts

Man

agem

ent

of

ou

tbre

aks

Org

anis

atio

n, c

on

tro

l an

d f

eed

bac

k o

n h

and

hyg

ien

e

Dec

isio

ns

on

tra

nsm

issi

on

-bas

ed p

reca

uti

on

s fo

r re

sid

ents

Dev

elo

pm

ent

of

care

pro

toco

ls

Sup

ervi

sio

n o

f d

isin

fect

ion

/ste

rilis

atio

nby Ownership type

Private (n = 54) 46 59 59 59 85 81 61 81 72 57

Voluntary (n = 34) 29 47 65 41 91 94 74 91 91 38

HSE (n = 136) 25 48 68 43 93 86 79 84 68 36

by Care Type

GN > 12 months (n = 88) 36 59 70 53 88 83 74 82 68 47

Private only (n = 40) 45 63 58 60 80 80 63 78 65 63

Voluntary only (n = 7) 43 71 71 57 100 86 71 86 86 71

HSE only (n = 41) 27 54 83 46 93 85 85 85 68 27

Mixed > 12 months (n = 46) 41 46 70 48 96 93 76 87 83 35

Intellectually disabled (n = 31) 13 39 42 26 94 87 65 84 71 23

LTCFs < 12 months (n = 14) 7 36 50 57 100 86 64 93 71 79

Psychiatric (n = 23) 22 35 61 26 87 70 74 70 48 22

Palliative care (n = 7) 29 86 71 86 71 100 86 100 100 86

Physically Disabled (n = 1) 100 100 100 0 100 100 100 100 100 0

Rehabilitation (n = 5) 40 60 100 40 100 100 80 100 100 20

National 31 50 65 46 91 86 74 84 73 42

% %

Surveillance General IPC activities



HCAI Surveillance Programme

Some form of a HCAI surveillance programme was reported by 31% (n=69) of LTCF (Table

3.1.6). Ongoing participation in repeated HALT surveys could be regarded as a HCAI

surveillance programme. Some care types were more likely to report having HCAI

surveillance activities; private GN>12 (45%), voluntary GN>12 (43%) and mixed >12 (41%).

HCAI surveillance was less common in psychiatric (22%), intellectually disabled LTCF (13%)

and LTCF <12 months (7%)

Audits of IPC policies and procedures were reported by 50%, feedback of surveillance results

to staff by 65% and monitoring of incidence of MDRO by 46%

Notably, facilities with an active IPCC were more likely to report having MDRO surveillance

programmes than those without

A designated staff member for reporting and management of infection outbreaks was

available in 86% overall, with lower levels reported from private LTCFs (81%)

A system in place for the organisation, control and feedback on hand hygiene was reported

as available in 74% overall, with lower levels reported from intellectually disabled LTCF

(65%), LTCF <12 months (64%) and private GN<12 (63%)

A system for management of patients with MDRO (e.g., patient isolation, additional IPC

precautions) was available in 84% overall, with less availability in psychiatric LTCF (70%) and

private GN>12 (78%)

Overall, a system for development of resident care protocols available in 73%, with lower

availability in HSE GN>12 (68%) and psychiatric LTCF (48%)

Overall, 91% reported that seasonal influenza vaccine is offered to residents. However,

lower figures were reported from psychiatric LTCF (87%) and private GN>12 (80%)



Antimicrobial Stewardship Practices

Antimicrobial stewardship practices, stratified by LTCF ownership, care type and presence of a

designated coordinating physician are displayed in Table 3.1.7.

Table 3.1.7 Antimicrobial stewardship practices, by LTCF ownership, care type and presence of a coordinating physician.

* Chi-test p-values that reached significance are highlighted in bold

An

tim

icro

bia

l ste

war

dsh

ip c

om

mit

tee

Trai

nin

g o

f p

resc

rib

ers

on

an

tim

icro

bia

l use

Gu

idel

ines

fo

r ap

pro

pri

ate

anti

mic

rob

ial u

se

Dat

a ab

ou

t an

tim

icro

bia

l co

nsu

mp

tio

n

Mic

rob

iolo

gica

l sam

ple

s ta

ken

bef

ore

an

tim

icro

bia

ls

Loca

l an

tim

icro

bia

l res

ista

nce

pro

file

su

mm

arie

s

Per

mis

sio

n f

or

pre

scri

bin

g re

stri

ctiv

ed a

nti

mic

rob

ials

Ph

arm

acis

t gi

vin

g ad

vice

on

an

tim

icro

bia

l use

Ther

apeu

tic

form

ula

ry a

vaila

ble

Feed

bac

k to

GP

s o

n a

nti

mic

rob

ial c

on

sum

pti

on

by Ownership type

Private (n = 54) 2 7 20 7 26 17 0 48 20 30

Voluntary (n = 34) 0 12 59 24 21 3 3 41 18 21

HSE (n=136) 3 4 50 11 16 8 0 35 35 7

by Care Type

GN > 12 months (n = 88) 2 5 34 9 26 15 0 43 28 22

Private only (n = 40) 3 8 20 8 28 18 0 45 20 33

Voluntary only ( n = 7) 0 14 43 29 43 0 0 71 14 57

HSE only (n = 41) 2 0 46 7 22 15 0 37 39 5

Mixed > 12 months (n = 46) 2 13 48 15 22 11 0 41 22 17

Intellectually disabled (n = 31) 0 6 42 16 3 3 3 13 10 13

LTCFs < 12 months (n = 14) 0 0 43 14 7 0 0 36 21 0

Psychiatric (n = 23) 4 4 43 4 13 4 0 61 52 4

Palliative care (n = 7) 0 14 100 29 43 0 0 57 71 0

Physically Disabled (n =1) 0 0 100 0 0 0 0 0 100 0

Rehabilitation (n = 5) 0 0 80 40 0 0 0 20 20 0

by Presence of a Coordinating Physician

With a CP 3 10 50 17 22 8 1 41 30 14

Without a CP 1 0 34 4 14 11 0 37 27 14

Chi-test (p-value) 0.53 0.001 0.03 0.004 0.14 0.45 0.67 0.57 0.63 0.92

National 2 6 44 12 19 9 0 39 29 14

%



Overview of Antimicrobial Stewardship Practices & Guidelines

The vast majority of LTCF (n=219; 98%) reported having no antimicrobial stewardship

committee (ASC). Of the five LTCF with an ASC (2%), one was privately-owned

Additionally, the vast majority (94%) reported that annual training on antimicrobial

prescribing was not provided

A local antimicrobial prescribing guideline was available in 99 LTCF (44%) overall. Private

GN>12 were less likely (20%) than palliative care (100%) and rehabilitation LTCF (80%) to

have guidelines

Most LTCF (n=193; 86%) reported having no restrictions on the types of antimicrobials that

could be prescribed for residents. Of the 31 LTCF that reported having a restricted

antimicrobial list, the types of restricted antimicrobials are displayed in Table 3.1.8

Table 3.1.8 Types of restricted antimicrobials.

Access to the advice of a pharmacist as required, was reported by 88 LTCF (39%) overall.

Voluntary GN>12 (71%), psychiatric (61%) and palliative care LTCF (57%) reported more

access to pharmacist advice

The HALT survey did not collect data on methods for gathering local consumption data. Local

antimicrobial consumption data was collected by the minority of LTCF (12%). It was

uncommon practice for antimicrobial consumption data to be reported back to GPs and very

uncommon for LTCF to report having access to summary reports of antimicrobial resistance

in key pathogens from their local microbiology laboratory (9%)

Restricted antimicrobialsNumber of

LTCFs (%)

Carbapenems 17 55

Intravenous antimicrobials 16 52

3rd generation cephalosporins 15 48

Vancomycin 14 45

Glycopeptides 9 29

Mupirocin 9 29

Fluoroquinolones 7 23

Broad-spectrum antibiotics 2 6

Total 31 100



A minority (19%) reported having a system in place to remind staff of the importance of

obtaining relevant clinical specimens from the resident prior to commencing antimicrobial

therapy for infection (e.g., the importance of taking a urine specimen before starting

treatment for a suspected UTI)

Information was sought regarding the frequency with which a urine dipstick test was used

for UTI diagnosis. Of the 219 (98%) who answered, urine dipstick was performed routinely in

133 (61%) and sometimes in 86 (39%)

Specific information was also sought on the availability of local antimicrobial prescribing

guidelines for three common infection types, as displayed in Table 3.1.9. Private LTCF were

less likely to have guidelines for RTI and UTI

Table 3.1.9 Written antimicrobial treatment guidelines.

When LTCF were stratified by the presence or absence of a coordinating physician, the

presence of a coordinating physician was significantly associated with a higher prevalence of

positive antimicrobial stewardship practices, in particular the training of prescribers on

antimicrobial use, availability of antimicrobial prescribing guidelines, including site specific

infection guidelines and antimicrobial consumption data

Respiratory

tract infections

Urinary tract

infections

Wound and soft

tissue infections

by Ownership

Private 22 39 35

HSE 32 51 34

Voluntary 41 56 35

With a CP 41 53 41

Without a CP 14 42 22

National 31 49 34

Antimicrobial treatment guidelines

by Presence of a

Coordinating

%



3.2 HCAI

Description of Residents

Table 3.2.1 displays an overview of the resident demographics, selected care load indicators and

HCAI risk factors, by LTCF ownership and by care type in Table 3.2.2. Female residents

predominated, other than in psychiatric and palliative LTCF. There were higher proportions of

residents aged ≥85 years in private LTCF (51%) and HSE LTCF (38%). GN>12 (49%), mixed care >12

(47%) and LTCF <12 months (41%) also had a higher proportion of residents ≥85 years. Nursing care

load indicators (incontinence, disorientation and impaired mobility) were evident, but varied in

prevalence across all care types. Overall, there was a heavy burden of all care load indicators in care

types: GN>12, mixed >12 and LTCF <12 months.

HCAI risk factors were most prevalent in palliative care LTCF, where urinary (31%), vascular (18%)

catheters, pressure sores (20%) and ‘other wounds’ (28%) were much more common than for other

care types. Overall, recent surgery within the past 30 days was uncommon (2%). Residents of the

physically disabled, psychiatric and intellectually disabled LTCF were less likely to have HCAI risk

factors.

Table 3.2.1 Resident demographics, care load indicators and HCAI risk factors, by LTCF ownership.

Gender Age

Ownership ma

le r

esi

de

nts

resi

de

nt

>8

5 y

ea

rs

inco

nti

ne

nce

dis

ori

en

tati

on

imp

air

ed

mo

bil

ity

uri

na

ry c

ath

ete

r

va

scu

lar

ca

the

ter

pre

ssu

re s

ore

s

oth

er

wo

un

ds

surg

ery

(<

30

da

ys)

Private (n=54) 31 51 56 55 37 6 0 3 9 1

Voluntary (n=34) 37 21 48 48 40 5 2 3 13 3

HSE (n=136) 42 38 58 49 47 7 0 4 9 2

National 38 39 56 50 43 7 1 3 9 2

%

Care load indicators HCAI Risk factors



Table 3.2.2 Resident demographics, care load indicators and HCAI risk factors, by care type.

Long-Term Care Facility-Acquired Infections (LAI)

There were 441 residents with 455 LAI, giving a national crude prevalence of LAI of 4.4%, with a

median prevalence of 3.4%. Table 3.1.3 displays the LAI prevalence, by care type. Similar to the

distribution of HCAI risk factors, as displayed in Table 3.2.2 above, the median prevalence of LAI was

highest in palliative care LTCF (8.3%). Higher median LAI prevalence was recorded for LTCF care

types associated with recent hospitalisation; LTCF <12 months (6.6%) and rehabilitation LTCF (4.9%).

LAI prevalence was lower in intellectually disabled and psychiatric LTCF.

Gender Age

Facility Type ma

le r

esi

de

nts

resi

de

nt

>8

5 y

ea

rs

inco

nti

ne

nce

dis

ori

en

tati

on

imp

air

ed

mo

bil

ity

uri

na

ry c

ath

ete

r

va

scu

lar

cath

ete

r

pre

ssu

re s

ore

s

oth

er

wo

un

ds

surg

ery

(<

30

da

ys)

GN > 12 months 35 49 61 57 47 6 0 3 9 1

Mixed > 12 months 36 47 59 54 46 8 0 4 10 2

LTCFs < 12 months 41 41 53 49 41 12 0 3 10 5

Intellectually disabled 47 1 47 38 32 2 0 1 9 1

Psychiatric 56 7 40 32 23 2 0 2 2 0

Palliative care 54 13 45 34 54 31 18 20 28 3

Physically Disabled 38 0 54 8 77 8 0 0 0 0

Rehabilitation 39 28 21 14 16 7 3 4 10 3

Other 39 29 43 44 35 7 1 2 24 16

National 38 39 56 50 43 7 1 3 9 2

Care load indicators HCAI Risk factors

%



Table 3.2.3 LAI prevalence, by care type.

a The crude prevalence of residents with a LAI is the total number of residents with an infection divided by the

total number of eligible residents.

b The interquartile range is the difference between the first quartile (25th percentile) and the third quartile

(75th

percentile) of an ordered range of data. It represents the middle fifty percent of the data.

Infection Types

Figure 3.2.1 displays the prevalence of LAI, by care type.

RTI

RTI was the joint most prevalent LAI, affecting 1.5% of all residents. In the HALT protocol, RTI

were further categorised into; lower RTI (85.6%), common cold (7.5%), pneumonia (6.2%)

and flu (0.7%), with the latter definition based on clinical symptoms only

UTI

UTI was the joint most prevalent LAI, affecting 1.5% of all residents. In total, 33.3% were

reported as microbiologically-confirmed UTI

UTI was the most prevalent (or one of the most prevalent) infections, reported by palliative

care (3.7%) and rehabilitation (3.3%) LTCF. UTI was less prevalent in intellectually disabled

LTCF (1.0%)

Crudea

GN > 12 months 4,722 189 4.0% 3.5 (0 - 6.2)

Mixed > 12 months 2,499 130 5.2% 4.5 (2.6 - 6.9)

LTCFs < 12 months 441 25 5.7% 6.6 (0 - 12.8)

Intellectually disabled 1,251 40 3.2% 0.0 (0 - 4.8)

Psychiatric 505 19 3.8% 0.0 (0 - 1.4)

Palliative care 134 16 11.9% 8.3 (2.9 - 16.1)

Physically Disabled 13 2 15.4% 15.4 (15.4 - 15.4)

Rehabilitation 245 12 4.9% 4.9 (0 - 10.9)

Other 234 8 3.4% 0.0 (0 - 5.4)

National 10,044 441 4.4% 3.40 (0 - 6.7)

Facility Type

Total eligible

residents

Number of

residents

with an

infection

LAI Prevalence (%)

Median (IQRb)



Skin infections

Skin infections were the second most prevalent LAI, affecting 1.1% of all residents. The vast

majority were further categorised as cellulitis (85%)

Skin infections were the most prevalent infections reported in intellectually disabled LTCF

(1.1%) and were slightly more prevalent in LTCF <12 months (1.4%) and mixed >12 months

(1.3%)

CDI

LTCF acquired C. difficile infection (CDI) affected 0.02% of all residents (n=3). All cases were

microbiologically confirmed

Figure 3.2.1 Percentage of residents with LAI, by care type. Only LTCF care types including > 100 eligible residents were included for this analysis. Some residents had >1 LAI. Within palliative care – ‘other’ category included oral candidiasis (n=5) and bloodstream infection (n=1).

Hospital-Acquired Infections (HAI)

For the first time, HALT 2016 collected data on hospital-acquired infections (HAI). There were 42 HAI

in 39 residents reported by 27 (12%) LTCF. The national crude prevalence of HAI was 0.4%, with a

median HAI prevalence of 0%. Therefore, HAI were uncommon in Irish LTCF in May 2016, with the

vast majority of HCAI categorised as LAI.



Table 3.2.4 displays the HAI prevalence, by care type. Similar to the distribution of HCAI risk factors,

as displayed in Table 3.2.2 above, the crude prevalence of HAI was highest in palliative care LTCF

(6%). A slightly higher crude HAI prevalence was recorded for LTCF care types associated with recent

hospitalisation; LTCF <12 months (0.9%) and rehabilitation LTCF (1.2%).

Table 3.2.4 HAI prevalence, by care type.

a The crude prevalence of residents with a HAI is the total number of residents with an infection divided by the

total number of eligible residents.

b The interquartile range is the difference between the first quartile (25th percentile) and the third quartile

(75th

percentile) of an ordered range of data. It represents the middle fifty percent of the data.

Infection Types

Figure 3.2.2 displays the prevalence of HAI, by care type.

RTI: Overall, RTIs were the joint most prevalent HAI, affecting 0.11% of all residents. RTI were further

categorised into; lower RTI (45.5%), common cold (9%) and pneumonia (45.5%)

Skin infections: Skin infections were the joint most prevalent HAI, affecting 0.11% of all residents. All

HAI skin infections were further categorised as cellulitis. Skin infections were the most prevalent (or

one of the most prevalent) infections reported by rehabilitation LTCF (0.4%)

UTI: Overall, UTI was the second most prevalent HAI, affecting 0.06% of all residents. None of these

were reported as microbiologically-confirmed UTI

Crudea

GN > 12 months 4,722 12 0.3% 0.00 (0 - 0)

Mixed > 12 months 2,499 10 0.4% 0.00 (0 - 0)

LTCFs < 12 months 441 4 0.9% 0.00 (0 - 1.3)

Intellectually disabled 1,251 1 0.1% 0.00 (0 - 0)

Psychiatric 505 1 0.2% 0.00 (0 - 0)

Palliative care 134 8 6.0% 0.00 (0 - 6.3)

Physically Disabled 13 0 0.0% 0.00 (0 - 0)

Rehabilitation 245 3 1.2% 0.00 (0 - 0)

Other 234 0 0.0% 0.00 (0 - 0)

National 10,044 39 0.4% 0.00 (0 - 0)

Facility Type

Total eligible

residents

Number of

residents

with an

infection

HAI Prevalence (%)

Median (IQRb)



CDI: C. difficile infection affected 0.04% of all residents. All four cases of CDI were microbiologically confirmed

SSI: Two residents (0.02%) were reported to have had surgical site infections, both of which were

superficial. Both were residents of GN>12 months. Neither were microbiologically-confirmed

Figure 3.2.2 Percentage of residents with HAI, by care type.

Only LTCF care types including > 100 eligible residents were included for this analysis. Some residents had >1

HAI. Within palliative care – ‘other’ category included oral candidiasis (n=3) and bloodstream infection (n=1).

Microbiology Results – Pathogens & Antimicrobial Resistance

In prior HALT surveys, whenever an antimicrobial was prescribed, information was sought regarding

whether or not a relevant microbiological sample had been taken from the resident prior to starting

the antimicrobial. In HALT 2016, the protocol changed, whereby information on microbiology

samples was sought only on residents who fulfilled a HCAI surveillance definition. Therefore, the

microbiology findings from 2016 are not comparable with those of previous HALT surveys. Within

this report, only the microbiology results for confirmed LAI will be considered. Figure 3.2.3 displays

the microbiology status of the 455 LAI.



Figure 3.2.3. Microbiology status of LAI.

For 284 infections, no specimen had been sent for microbiological examination (62%). Of 171 LAI

with a microbiology specimen sent, the result was pending or unavailable for 84 (49%), a mixed

culture was reported for 22 (13%). There were 65 LAI with at least one microorganism detected. In

total, there were 70 microorganisms reported, with five LAI having two or more reported

microorganisms.

Figure 3.2.4 displays the reported microorganisms for LAIs. Escherichia coli (E. coli) was the most

frequently detected (35%), followed by Staphylococcus aureus (29%).

Figure 3.2.4. LAI causative microorganisms.



Figures 3.2.5 and 3.2.6 display the proportion of pathogens reported from relevant positive

microbiological specimens taken from urinary tract and skin/wound LAIs. E. coli was the most

frequently isolated organism of 36 UTI with positive microbiology (62%, n=22), with S. aureus the

most frequently isolated organism from 17 skin/wound infections with positive microbiology (82%,

n=14). Just two RTIs had positive microbiology; Serratia marcescens (n=1) and unspecified Candida

species (n=1),with the latter likely colonising flora in the setting of RTI.

Figure 3.2.5 Causative pathogens of LTCF-acquired UTIs

Figure 3.2.6 Causative pathogens of LTCF-acquired skin/wound infections

Of 23 E. coli isolates, 3rd generation cephalosporin (3GC) susceptibility results were unknown for

52%, 44% were susceptible to 3GC, 4% were resistant to 3GC. There were no LAI with a positive

microbiology result for carbapenem resistant Enterobacteriaceae (CRE) reported (Figure 3.2.7).



Figure 3.2.7 E. coli antimicrobial susceptibility results.

Of 19 Staphylococcus aureus isolates, 74% were susceptible (MSSA) and 16% were resistant to

meticillin/flucloxacillin (MRSA). For 10%, antimicrobial susceptibility results were unknown. (Figure

3.2.8)

Figure 3.2.8 Staphylococcus aureus antimicrobial susceptibility results.



3.3 Antimicrobial Use

The national crude prevalence of antimicrobial use was 9.8%, with a median prevalence of 8.3%.

Table 3.3.1 displays antimicrobial use prevalence, by care type. The median prevalence was highest

in palliative care LTCF (30.8%).

Table 3.3.1 Antimicrobial use prevalence, by care type.

Antimicrobial Prescribing Location

Across all care types, 83% of antimicrobials were prescribed within the LTCF, as displayed in Figure

3.3.1. A higher proportion of antimicrobials had been prescribed in the hospital for rehabilitation

(21%) and palliative care (16%) LTCF and LTCF <12 months (13%).

Figure 3.3.1 Antimicrobials, by prescribing location and care type.

Crude

GN > 12 months 4722 444 9.4 8.6 (5.3-13.6)

Mixed > 12 months 2499 250 10.0 8.2 (5.7-12.5)

LTCFs < 12 months 441 49 11.1 12.1 (6.9-19)

Intellectually disabled 1251 102 8.2 5.2 (0.3-16.7)

Psychiatric 505 39 7.7 6.7 (2.4-9.2)

Palliative care 134 44 32.8 30.8 (25.7-36.3)

Physically Disabled 13 0 0.0 0.0 (0-0)

Rehabilitation 245 22 9.0 10.9 (6.6-15.6)

Other 234 31 13.2 15.0 (9.1-17.6)

National 10044 981 9.8 8.3 (4.5-15.1)

Care TypeTotal eligible

residents

Number of

residents on

antimicrobials

Antimicrobial prevalence (%)

median (IQR)



Body Sites for which Antimicrobials were Prescribed

Figures 3.3.2 and 3.3.3 display the breakdown of antimicrobial use, by body site and antimicrobial

indication, respectively. Over one third (36%) of therapeutic antimicrobials were prescribed for RTI.

The majority of prophylactic antimicrobials (68%) were prescribed to prevent UTI.

Figure 3.3.2 Treatment antimicrobial use by body site (n=615) & Figure 3.3.3. Prophylactic antimicrobial use by body site (n=434)

Figure 3.3.4 displays the antimicrobial use prevalence, by body site across the care types.

The urinary tract was the most prevalent site, accounting for antimicrobials prescribed to 5%

of all residents. Palliative care (7%) had a slightly higher prevalence, while psychiatric,

rehabilitation (both 4%) and intellectually disabled (2%) LTCF had a lower prevalence of

prescribing for urinary tract indications

The respiratory tract was the second most prevalent site, accounting for antimicrobials

prescribed to 3% of all residents. Palliative care (6%) had a higher prevalence than other

facility types

Skin or wounds were the third most prevalent site, accounting for antimicrobials prescribed

to just under 2% of all residents. Palliative care (5%) & intellectually disabled (3%) LTCF had a

higher prevalence of prescribing for skin or soft tissue indications than other facility types

Treatment Prophylaxis



Figure 3.3.4 Prevalence of antimicrobial use, by body site and care type. Only LTCF care types including > 100 eligible residents were included in this breakdown.

Reasons for which Antimicrobials were Prescribed

The reason for antimicrobials varied across care types, as displayed in Figure 3.3.5. Overall, the

majority were prescribed to treat infection (59%). However, the opposite was true in intellectually

disabled LTCF, where prophylaxis accounted for the majority of antimicrobial prescriptions (54%).

Figure 3.3.5 Reason for antimicrobials, by care type.



Figure 3.3.6 displays the breakdown of treatment antimicrobials, by care type. RTI was most

prevalent indication (2.1% of all residents), particularly in palliative care (5.2%) and LTCF <12 months

(3.2%). UTI treatment was prevalent in palliative care (5.2%) and rehabilitation (2.9%). Skin/wound

infection treatment was most prevalent in palliative care (5.2%) and LTCF <12 months (1.8%).

Figure 3.3.6 Body sites for treatment of infection, by care type. Only LTCF care types including > 100 eligible residents were included in this breakdown.

Figure 3.3.7 displays the breakdown of prophylactic antimicrobials, by care type. UTI prevention was

the most prevalent indication and at 3.4% was highest in Mixed>12m, followed by LTCF <12m (3.2%)

and GN>12 months (3.1%). Respiratory tract prophylaxis was particularly prevalent in intellectually

disabled (2.0%) and palliative care (1.5%) LTCF.

Figure 3.3.7 Body sites for prevention of infection (prophylaxis), by care type. Only LTCF care types including > 100 eligible residents were included in this breakdown.



Prescribed Antimicrobials

Nitrofurantoin was the most commonly prescribed antimicrobial. Trimethoprim, co-amoxiclav,

flucloxacillin, amoxicillin, cefalexin and azithromycin were also frequently prescribed, as displayed in

Figure 3.3.8. Figures 3.3.9 & 3.3.10 display the breakdown of the top five treatment and prophylaxis

antimicrobials, respectively.

The oral route accounted for 95% of antimicrobial administration overall, with treatment

antimicrobials administered via the oral route in 91.5%, the parenteral (IV) route in 6.5%, with 2%

administered via other routes (e.g., inhaled). There were no residents prescribed tuberculosis

treatment at the time of the HALT survey. Figure 3.3.11 displays the breakdown of prescribed

antimicrobials, by care type. Co-amoxiclav accounted for 41% of prescriptions in psychiatric LTCF.

Figure 3.3.8 Top five antimicrobials prescribed in LTCF, overall

Figure 3.3.9 Top five treatment antimicrobials Figure 3.3.10 Top five prophylactic antimicrobials

Treatment Prophylaxis



Figure 3.3.11 Prescribed antimicrobials, by care type.



4. Previous HALT Surveys

The 2016 HALT survey was the fourth such PPS performed in Irish LTCF. A review of the key HCAI and

antimicrobial use prevalence results across the four HALT surveys (May 2010, 2011, 2013 and 2016)

is described in this section. Please see the ‘Methods’ section for a more detailed description of

differences in the methodology between the HALT surveys. Hospital-acquired infection data was

collected in HALT 2016 only.

LTCF-acquired infection (LAI): 2010 - 2016 Owing to differences in methodology and infection surveillance definitions, caution should be taken

when reviewing the annual infection prevalence results of 2010 and 2011 versus 2013 and 2016, as

they are not directly comparable. Table 4.1.1 displays an overview of the four HALT surveys. There

was an annual increase in the number of participating LTCF and residents surveyed.

Table 4.1.1 LAI: 2010 – 2016.

a

Adapted McGeer: McGeer definition using physician diagnosis as a criterion. [4]

b As defined by Stone et al 2012.[6]

The three commonest care types in all four HALT surveys were; GN >12 months, Mixed >12m and

intellectually disabled LTCF. Table 4.1.2 displays the annual number of participants, eligible residents

and median infection prevalence for each care type. Again, caution should be taken when reviewing

the annual infection prevalence results, as they are not directly comparable.

2010a 2011a 2013b 2016

Number of LTCFs that participated in survey 69 108 190 224

Number of residents surveyed 4170 5922 9318 10044

Number of residents with signs/symptoms of an infection 266 384 563 638

Number of residents with infectionsa 149 242 497 441

Number of infections 156 253 511 455

Residents with more than one infection 7 11 14 14

Crude prevalence of residents with a LTCF-acquired infection, % 3.6 4.1 5.3 4.4

National median prevalence, % 2.8 4.2 4.2 3.4

National interquartile range, % 0 - 5.5 1.9 - 7.2 1.9 - 8.3 0-6.7

Year

National LTCF-acquired infection prevalence data



Table 4.1.2 LTCF-acquired infection prevalence in the three commonest care types: 2010 – 2016.

Infection Types

The annual breakdown of infection types is displayed in Figure 4.1.1. Caution is required when

reviewing the annual results, because substantial revisions were made to the definitions of some

infection types in the 2013 HALT survey:

The RTI categories of cold/pharyngitis and influenza no longer included the criterion

‘physician diagnosis’: The definitions of the HCAI types, pneumonia and other lower RTI

were also revised to reflect the revised SHEA/CDC criteria

The UTI category was revised to reflect the revised SHEA/CDC criteria. While residents with

suspected UTI were stratified by presence or absence of a urinary catheter, the criterion

‘physician diagnosis’ was removed and UTI were ultimately categorised as ‘confirmed’ or

‘probable’ based on availability of a urine culture result

Care type YearNumber of

LTCFs

Number of

residents

Median

Infection

prevalence

GN > 12 months 2010 30 2487 2.7

2011 58 3916 3.95

2013 103 5807 4.2

2016 88 4722 3.5

Mixed > 12 months 2010 16 660 1.45

2011 16 778 2.85

2013 26 1409 6.1

2016 46 2499 4.5

Intellectually disabled 2010 8 510 2.4

2011 15 740 4.8

2013 24 1060 2.2

2016 31 1251 0.0



Figure 4.1.1 Prevalence of HCAI types: 2010 – 2016.

Antimicrobial Use: 2010 - 2016 Table 4.1.3 provides an overview of the antimicrobial use prevalence across the four HALT surveys.

While the crude prevalence has remained stable, there was a welcome decrease in the median

prevalence from 2011 to 2016 (10% versus 8.3%). There has been no increase in the proportion of

antimicrobials administered via the intravenous route across the four surveys. The vast majority

were administered via the oral route.

Table 4.1.3 Antimicrobial use prevalence: 2010 – 2016.

National antimicrobial prevalence data 2010 2011 2013 2016

Number of residents surveyed 4170 5922 9318 10044

Number of residents on antimicrobials 426 601 913 981

Number of antimicrobials prescribed 453 636 971 1049

Number of residents on more than one antimicrobial, (%) 25 (0.6) 34 (0.6) 55 (0.6) 60 (0.6)

Crude prevalence of residents on antimicrobials, % 10.2 10.2 9.8 9.8

National median prevalence, % 9.5 10 9.7 8.3

National interquartile range, % 5.3 - 14.3 7.4 - 14.2 5 - 14.5 4.5 - 15

Year



Body Sites and Reasons for which Antimicrobials were Prescribed

Figure 4.1.2 displays the annual breakdown of the antimicrobial use prevalence, by body site.

Although the urinary tract remained the most frequent site for which antimicrobials were

prescribed, the proportion of residents on antimicrobials for the urinary tract declined between

2010 and 2013 (5.8% to 4.6%) but increased slightly in 2016 (4.7%). Conversely, there was an

increase in the proportion of residents on antimicrobials for the respiratory tract between 2011 and

2013 (2.3% to 2.9%), which remained stable in 2016.

Figure 4.1.2 Breakdown of antimicrobial use prevalence, by body site: 2010 – 2016.

Figure 4.1.3 displays annual trends in the reasons for antimicrobials. Although a downward trend in

the prevalence of prescribing for prophylaxis was observed between 2010 and 2013 (4.3% to 3.8%),

this increased to 4.3% in 2016. The prevalence of prescribing for treatment of infection increased

slightly from 2011 to 2016 (5.7% to 6.1%).

Figure 4.1.3 Reasons for prescribed antimicrobials: 2010 – 2016.



Figure 4.1.4 displays annual trends in the prevalence of prophylaxis and treatment, by body site.

There was a decrease in UTI prophylaxis between 2010 and 2013 (3.8% to 2.8%) followed by a slight

increase to 2.9% in 2016. RTI prophylaxis has increased across the four HALT surveys (0.2% to 0.8%).

The prevalence of antimicrobial treatment has remained relatively stable.

Figure 4.1.4 Reasons for prescribed antimicrobials by body site: 2010 – 2016.

Antimicrobial Use by Care Type

The three commonest care types in all HALT surveys were GN >12 months, Mixed >12 months and

intellectually disabled LTCF. Table 4.1.4 displays the annual number of participating LTCF, eligible

residents and median antimicrobial use prevalence (overall, prophylactic and therapeutic) for each

of those three care types. While the median overall antimicrobial use prevalence decreased in the

GN>12 group between 2010 and 2016 (11.9% to 8.6%), there was an increase in the prevalence of

antimicrobial prophylaxis (2.8% to 3.8%). Median antimicrobial prophylaxis prevalence decreased in

intellectually disabled LTCF (1.8% - 0%). In 2016, there was a decrease in the median antimicrobial

treatment prevalence for all three care types.



Table 4.1.4 Antimicrobial use prevalence in the three commonest care types: 2010 – 2016.

Thirty-nine LTCF have participated in all four HALT surveys to date. Figure 4.1.5 displays the

collective LAI and antimicrobial use prevalence (overall, therapeutic and prophylactic) for those 39

LTCF, versus the collective LAI and antimicrobial use prevalence for the 96 LTCF that participated in

HALT for the first time in 2016.

Figure 4.1.5 2016 LAI and antimicrobial use in first time HALT participants (n=96 blue) versus LTCF

that performed all four HALT surveys to date (n=39 red).

Overall Prophylactic Therapeutic

median median median

GN > 12 months 2010 30 2487 11.85 3.7 5.65

2011 58 3916 10.25 2.9 6

2013 103 5807 9.1 2.8 5.1

2016 88 4722 8.6 3.8 4.2

Mixed > 12 months 2010 16 660 9.6 4.05 4.55

2011 16 778 11.6 4.35 5.3

2013 26 1409 11.2 3.1 6.8

2016 46 2499 8.2 3.2 4.4

Intellectually disabled 2010 8 510 4.6 0 4.1

2011 15 740 5.4 1.9 2.9

2013 24 1060 7.5 1.8 4.4

2016 31 1251 5.2 0 4.0

Care type

Antimicrobial prevalence (%)

YearNumber of

LTCFs

Number of

residents


Discussion 61

5. Discussion Ireland contributed approximately 10% of the total resident population in the 2010 and 2013

European HALT surveys, with 2016 data expected from ECDC in 2018. Four HALT surveys have been

undertaken in Ireland (May 2010, 2011, 2013 and 2016) and there has been a welcomed annual

increase in the numbers of participants, including HSE, voluntary and private LTCF. In 2016, 96 LTCF

performed their first HALT survey (43%). This highlights the ongoing dedication of healthcare

professionals in Irish LTCF to improving the quality and safety of resident care. However, the

majority of residential care facilities registered with HIQA did not participate in HALT 2016. It is

recommended that evidence of each LTCF’s participation in HALT surveys be actively sought during

future monitoring inspections conducted by Health Information & Quality Authority (HIQA) and the

Mental Health Commission (MHC) and that all LTCF are encouraged to and facilitated in participating

in future HALT surveys.

The voluntary HALT survey provides participants with valuable information regarding infrastructure,

staffing, models of medical care, IPC and antimicrobial stewardship practices, resident dependency

levels, HCAI risk factors, HCAI and antimicrobial prescribing in Irish LTCF. The HALT survey clearly

demonstrates the diversity within the Irish long-term care population. In an attempt to reflect this

and provide a more meaningful interpretation of the data collected, LTCF were subdivided into eight

separate care types, which best reflected the typical characteristics and length-of-stay for the

majority of residents. The top three care types combined, which were predominantly long-stay

facilities (GN>12m, Mixed>12m and intellectually disabled LTCF), accounted for 84% of residents

surveyed. The results demonstrate differences between Irish LTCF care types, with regard to

resident demographics, nursing care load indicators, HCAI risk factors, LAI & HAI prevalence,

infection types, antimicrobial use prevalence and antimicrobial prescribing practices. The female

gender predominated across LTCF care types, other than psychiatric and palliative care LTCF.

Residents of intellectually disabled, psychiatric and palliative care LTCF tended to have a younger age

profile than residents of other care types. In November 2016, participating LTCF were provided with

a HALT report displaying the local results and enabling comparison with the collective results for

LTCF of the same care type. For prior HALT participants, review of the LTCF’s performance over time

was also provided.


Discussion 62

Standards

In Ireland, facilities providing residential care to older people are legally required to register with

HIQA. In 2009, HIQA published National Quality Standards for Residential Care Settings for Older

People in Ireland and updated Standards were published in 2016, with facilities inspected by HIQA

according to these standards. (10,11) There were 580 older persons LTCF listed as registered on

HIQA’s website in February 2017.

Inpatient facilities providing care and treatment to people with a mental illness must be listed on the

register of approved centres, maintained by the MHC, the responsible body for regulating and

monitoring mental health services in Ireland. In 2007, MHC published a Quality Framework for

Mental Health Services in Ireland, which comprises 24 standards and mental health services are

monitored according to these standards. (14) According to the MHC Annual Report for 2015, there

were 61 approved centres with 2,767 beds in December 2015. (41) The addition of a requirement for

psychiatric LTCF to undertake HCAI prevention and antimicrobial stewardship to the MHC’s

standards should be progressed as a matter of priority, particularly as the crude infection prevalence

in psychiatric LTCF was very similar to that in GN>12m (3.8% and 4.0%, respectively).

Effective November 1st 2013, HIQA became the responsible body for regulation of residential

services for children and adults with disabilities. This followed publication of the National Standards

for Residential Services for Children and Adults with Disabilities in January 2013. (15) According to

the National Intellectual Disability Database (NIID), in December 2015, there were 7,724 people in

residential care settings in Ireland. (45)

Staffing

The requirement for each LTCF to have sufficient staff with necessary skills to deliver safe resident

care is enshrined in HIQA Standards for residential care of older people and people with disabilities

and in the MHC standards for psychiatric facilities. (11, 14, 15)

The 2016 HALT survey sought information on nurse and healthcare assistant staffing levels within

participating LTCF for the first time. The analysis for the European HALT survey reports published to

date have focused on nursing homes and mixed care type LTCF only. Upon publication of the

European HALT report by ECDC, which is expected during 2018, it will be possible to compare both

nurse and HCA staffing levels in the general nursing homes and mixed care type LTCF in all EU

Member States.


Discussion 63

The nurse and HCA staffing data collected in HALT 2016 are not representative of the national

picture and should not be used to interpret nurse and HCA staffing levels for Irish LTCF in general, for

many reasons including; heterogeneity in care types, different categories of LTCF ownership, the

voluntary nature of the HALT survey, with incomplete participation in 2016. The wide range in

numbers of participating HSE-owned LTCF precluded analysis by CHO. Additionally, selected resident

care load indicators were collected in HALT, with no information on resident dependency or

comorbidities collected, which directly influence staffing levels within LTCF.

The HALT survey results have consistently demonstrated differences in the models of resident

medical care delivery, by ownership and geographical location. GP-led medical care is the preferred

model in privately-owned LTCF and when stratified by CHO, much commoner in CHOs 1, 2, 4, and 8

(Figure 3.1.2 and Appendix E). Regardless of the preferred medical care model, in accordance with

HIQA and MHC standards, each facility should have a clearly defined management structure, to

incorporate a defined system of clinical governance. The designation of a coordinating physician

role, with oversight of all elements of resident medical care is a valuable addition to LTCF

governance structures, especially as the median capacity of LTCF participating in HALT 2016 was 42

beds. In HALT 2016, the coordinating physician role was established in 62% of Irish LTCF overall (up

from 45% in 2013) and 56% of privately-owned LTCF (up from 26% in 2013).

The model of primary care delivery in Ireland is unique, with medical care delivered both by group

GP practices and individual GPs, with patients having the right to select their own GP. For example, if

a resident’s medical care in the community has been delivered by his or her local GP, the resident

may prefer to remain under their own GP’s care after moving into a LTCF. It is important that every

effort is made to accommodate a resident’s own preference for his/her medical care. Where a LTCF

already has or plans to develop a designated coordinating physician post, it is particularly important

that the GP-led and coordinating physician-led models of medical care do not become mutually

exclusive and that residents benefit from the input of both types of healthcare professional.

There are many potential duties for a coordinating physician, depending upon the needs of each

LTCF’s resident population. The HALT survey results demonstrate how the presence of a

coordinating physician was consistently associated with a higher prevalence of positive antimicrobial

stewardship practices. Access to a coordinating physician would undoubtedly have other potential

benefits for resident medical care, beyond antimicrobial stewardship practices.

A recommended intervention is the resourcing of external healthcare professionals to provide

specialist advice to all of the LTCF within a CHO, regardless of ownership. For example, the


Discussion 64

resourcing of specialist input from a geriatrician with a community remit to review residents and

their prescribed medicines, to identify opportunities to refine chronic medications and minimise

polypharmacy issues and the input of a clinical microbiologist with a community remit, to provide

advice and oversee the development of antimicrobial stewardship, infection prevention and control

education, guidelines and surveillance programmes, as part of a wider multi-disciplinary community

IPC and antimicrobial stewardship team.

There is undoubtedly a severe shortage of specialist IPC resources for Irish LTCF. Almost one quarter

of all LTCF participating in HALT 2016 (24%) reported having no access to a staff member with

specialist IPC training, which reflects an improvement from 38% without access in HALT 2013. The

deficit was even more marked in privately-owned LTCF (43%), but improved from 90% in HALT 2013.

Additional analysis performed after HALT 2013, reported an overall estimated WTE IPCN:LTCF bed

ratio for Ireland of 1:496 which was much higher than the 1:250, previously recommended by a

Canadian expert group. (16) It should be noted that the Canadian recommendation was based on an

evaluation of IPCNs working specifically within LTCF and did not take into account the much broader

remit of the community-based IPCN role in Ireland. Typically, community IPCNs are involved in

provision of IPC advice, education and training, development of policies, procedures and guidelines,

audit and surveillance activity across the breadth of community health services, incorporating

primary care, dentistry and long-term care. Therefore, it could be anticipated that the adequate

community IPCN resource required in Ireland could be even higher than 1:250 LTCF beds. During

2015, the HSE HCAI & AMR Clinical Programme commenced a project to identify current IPCN

resources for non-acute healthcare settings in Ireland. Key findings included; variance in the IPC

service provided across LTCF, with many areas reporting limited or no access to an IPCN, a lack of

clarity regarding the job specification for community IPCNs, with many working in isolation without

the support of a multi-disciplinary team, covering large geographical areas, without administrative

support and a lack of clarity surrounding governance and reporting relationships within CHOs, which

were established in 2014. There is a need for each CHO to undertake a gap analysis of existing

community IPCN resources and to develop a workforce plan to recruit sufficient numbers of

community IPCNs, who will have a remit over all LTCF within the CHO, regardless of care type or

ownership. Building multi-disciplinary IPC and antimicrobial stewardship teams within each CHOs is a

critical intervention to address the priorities identified from HALT surveys performed to date.

It is also important to make the distinction between the knowledge and skills of a healthcare

professional with specialist IPC training (IPCN) and a healthcare professional (e.g., staff nurse) who

has received some introductory IPC training and has an interest in supporting the practice of the


Discussion 65

IPCN specialist, the so-called IPC link nurse or link practitioner. (17) In addition to enhancing the

skills and practice of the IPC link practitioner, such roles support and facilitate the specialist role of

the IPCN. In recent years, courses providing an introduction to HCAI and IPC for healthcare workers,

including LTCF staff have been faciliated by the HPSC, the Royal College of Surgeons in Ireland,

University College Cork and the University of Limerick. While the development of an IPC link nurse

role within each LTCF should be facilitated and encouraged, it cannot replace the urgent need to

improve the overall specialist community IPCN staffing levels in Ireland.

Links between the acute hospital and LTCF

Infection acquired within LTCF is a common issue, with a crude prevalence of 4.4% in all LTCF

residents in May 2016. This figure is similar to the crude prevalence of hospital-acquired infection

(HAI) reported from the May 2012 hospital PPS during which 9,030 inpatients in 50 acute hospitals

were surveyed and 5.2% were reported to have a HAI. (18) The hospital PPS will be repeated across

Ireland in May 2017.

For the first time, HALT 2016, collected data on HAI, in addition to long-term care acquired infections

(LAI), which has been collected as part of all HALT surveys to date. The addition of a HAI category

added complexity to the HALT protocol and data collector training. A data field ‘infection imported’

was added to the resident questionnaire to capture HAI. This was straightforward if a resident

developed signs and symptoms matching the surveillance case definition and required timeline for

HAI (e.g., symptom onset on day one or day two after discharge from hospital to the LTCF or specific

timelines for CDI and SSI). However, if a resident was transferred from hospital to the LTCF already

on treatment for a HAI which had begun while in the hospital, the protocol allowed the resident to

be categorised as having a HAI, despite data collectors not having access to documented evidence of

signs or symptoms for the infection which started in the hospital. This questions the validity of the

categorisation of such HAI, in the absence of access to documentation that the surveillance

definition for the infection was actually met. In 2016, just 12% of LTCF reported a total of 42 HAI,

with the vast majority of all HCAI (455; 92%) acquired within the LTCF (LAI). These findings and the

practical difficulties encountered during training and data collection support a recommendation that

HAI data is excluded from future European HALT surveys.

During HALT 2013, 2% of LTCF residents were absent from the facility owing to hospitalisation. This

data was not captured in HALT 2016. The 2013 results highlighted the frequent exchange of

patients/residents between acute hospitals and LTCF. LAI may result in residents requiring

hospitalisation for further management. Additionally, in the period following an acute illness for


Discussion 66

which hospitalisation is required, a LTCF resident may be more vulnerable to acquiring infection. It is

critically important to ensure excellent communication between the acute hospital and the LTCF,

especially when residents are being transferred between the two settings. For example, where

hospital referral becomes indicated for a resident with a transmissible infection such as influenza-

like illness or diarrhoea of potentially infectious aetiology or a resident has a positive result for an

antimicrobial resistant organism (e.g., MRSA, ESBLs, CRE/CPE, VRE etc.) or a resident is being

transferred from a LTCF with an ongoing outbreak, this information must be conveyed to the

receiving healthcare facility to ensure safe placement and management of the resident. Likewise,

where the resident is transferred back to the LTCF, all relevant information (e.g., colonisation or

infection with antimicrobial resistant organisms, presence of indwelling devices, ongoing

antimicrobial therapy and infection issues) must be provided by the hospital to the LTCF prior to the

arrival of the resident, again to faciliate safe placement and management. With this in mind, it is

recommended that the development of a generic inter-facility transfer template to capture critical

information should be progressed at a national level and disseminated for local implementation by

all acute hospitals and LTCF.

Antimicrobial stewardship & surveillance

After four HALT surveys, while the crude prevalence of antimicrobial use in Irish LTCF has remained

unchanged, with around 1 in 10 residents prescribed antimicrobials, the median prevalence has

decreased, from 10% (2011) to 8.3% (2016). The 2013 European HALT report found that residents of

Irish LTCF were more than twice as likely to be on an antimicrobial than their European

counterparts, where the crude prevalence of antimicrobial use was just 4.4%. Ireland ranked sixth

highest of 19 EU Member States participating in HALT 2013 for the proportion of prophylactic

antimicrobials. (6) It is a positive finding that for the 39 Irish LTCF that have participated in all HALT

surveys to date, overall antimicrobial prevalence (8.8%), therapeutic prevalence (5.1%) and

prophylactic prevalence (3.7%) was lower than for the 96 LTCF participating in their first HALT in

2016 (9.8%, 5.4%, 4.4%, respectively).

Guidelines for antimicrobial prescribing in primary care in Ireland were issued in 2010 and are

periodically updated by the Primary Care Antimicrobial Guidelines Editorial Group. The guidelines

are available as a web version, suitable for use on mobile devices. The guidelines are endorsed by

the RCPI & HSE Clinical Advisory Group for HCAI and AMR and by the Irish College of General

Practitioners (ICGP) and it is recommended that these guidelines are used to guide prescribing in

LTCF. Co-amoxiclav is rarely recommended for treatment of infection in the community. In the Irish

guidelines, co-amoxiclav is a first line antimicrobial for quite limited infection indications (e.g.,


Discussion 67

pyelonephritis, bite wounds) and a second line antimicrobial for sinusitis and infective exacerbations

of COPD unresponsive to first line treatments. Despite the recommendations of national guidelines,

in HALT 2016, co-amoxiclav accounted for 41% of all antimicrobials in psychiatric LTCF, versus 11 –

14% for all other care types. Of therapeutic prescriptions, co-amoxiclav was the most commonly

prescribed antimicrobial accounting for 38% of all prescriptions. Formal implementation of the

primary care prescribing guidelines within all Irish LTCF, regardless of care type is recommended and

has potential to positively impact on unnecessary use of broad spectrum antimicrobials, such as co-

amoxiclav. The guidelines may be viewed at www.antibioticprescribing.ie

Periodic PPS is useful to monitor trends over time, but can’t provide the same level of comparative

data as undertaking prospective incidence surveillance. It is recommended that HALT participants

build on HCAI and antimicrobial stewardship surveillance skills, developed from participation in HALT

surveys. Potential areas for local prospective surveillance by LTCF could include:

1. Daily monitoring of residents for new-onset of ‘alert’ symptoms and signs (fever, influenza-

like-illness, diarrhoea, vomiting, conjunctivitis, rash etc.). Such a programme would greatly

facilitate the early identification of potentially transmissible infections and mitigate the

development of outbreaks

2. Surveillance of UTI

3. Surveillance of C. difficile infection

4. Periodic surveillance of antimicrobial use, which might be incorporated into the requirement

for quarterly medicines reconciliation. This could be used to identify residents prescribed

prophylaxis, to review and discontinue such antimicrobials, where appropriate and to audit

compliance with local prescribing guidelines

It is recommended that surveillance protocols, training and user-friendly data collection methods for

incidence surveillance be developed specifically nationally, for use by LTCF within each CHO.

In HALT 2016, microbiology data was gathered for residents who met the case definition for

infection. This differs from previous HALT surveys when microbiology data was gathered for

residents prescribed antimicrobials, regardless of infection. Therefore, the microbiology data from

2016 is not comparable with prior HALT surveys. For the purposes of this report, analysis of

microbiology relates to LAI only, as microbiology results may not have been available to data

collectors for HAI, whereby specimens were submitted while the resident remained in hospital.

For the majority of LAI, no microbiology specimen was submitted to the laboratory (62%), with

microorganisms reported in just 14% of specimens taken from residents with LAI. The presence of a

http://www.antibioticprescribing.ie/


Discussion 68

microorganism in a clinical specimen does not necessarily confirm it was the causative pathogen of

the LAI (e.g., detection of candida from sputum reflects colonisers, rather than pathogens).

Although the issue of AMR has been long-recognised, it has received increasing attention in recent

years. Of particular concern is the successful dissemination of resistant Enterobacteriaceae (e.g., E.

coli and K. pneumoniae) both in acute hospitals and LTCF. Infections caused by these bacteria are

associated with increased morbidity and mortality. (19) Resistance genes encoding production of

extended spectrum β lactamases (ESBLs), carbapenemases and conferring resistance to additional

antimicrobial classes (e.g., fluoroquinolones and aminoglycosides), whereby bacteria are termed

multi-drug resistant (MDR) transmit readily. Outbreaks and increasing prevalence of antimicrobial

resistant Enterobacteriaceae are well-described in Irish LTCF. (20 – 22) Indeed, Enterobacteriaceae

(E. coli, K. pneumoniae, Proteus mirabilis and other Enterobacteriaceae) were the commonest

microorganisms reported from residents with LAI in HALT 2016.

The prevalence of MDR-Enterobacteriaceae (i.e., ESBL positive and resistant to both fluorquinolones

and aminoglycosides or carbapenemase-producers) has exhibited large increases in Ireland since

2010, with cases reported from both acute hospitals and LTCF (Source: HPSC). Increasing incidence

of MDR-K. pneumoniae (MDRKP) resulted in the establishment of a national enhanced surveillance

system in 2014. To the end of Q3 2016, it had become evident that MDRKP are widely disseminated

across the Irish healthcare system, with 15% of isolates reported from LTCF residents (Source: HPSC).

Of even greater concern, 16% of those were also carbapenem resistant (CRE).

Resistance to 3rd generation cephalosporins (3GC) is a potential marker for ESBL production.

Unfortunately, 3GC susceptibility results were unavailable for 52% of E. coli isolates in HALT 2016,

with 4% confirmed 3GC resistant. Fortunately, there were no cases of CRE reported during HALT

2016.

Improvements have been demonstrated in Ireland and abroad with regard to the proportions of

invasive infections caused by MRSA. In HALT 2016, Staphylococcus aureus accounted for 29% of

reported microorganisms, with 16% of S. aureus reported as MRSA.

From the HALT survey, it is evident that Irish LTCF rarely receive information regarding the

antimicrobial resistance profiles of common pathogens from their local microbiology laboratories.

Such information is important for the development of local prescribing guidelines and to inform

antimicrobial stewardship within LTCF.

Strict attention to standard and transmission-based precautions by all healthcare workers, careful

antimicrobial stewardship, excellent communication between the acute hospital and LTCF, coupled


Discussion 69

with ongoing healthcare worker education and surveillance are critical to halting the progressive

dissemination of antimicrobial resistant bacteria.

It is recommended that regional HCAI and AMR Committees are established within each CHO, with

governance over all LTCF within the CHO, regardless of care type or ownership and multi-disciplinary

membership, including representation from LTCF, local acute hospitals and their microbiology

laboratories, community pharmacies, Departments of Public Health and the multi-disciplinary

community IPC & antimicrobial stewardship teams. Such Commitees should be resourced to provide

support to all LTCF within the CHO, with regard to education and training, surveillance activities,

data analysis, monitoring of agreed key performance indicators (KPIs) and feedback of comparative

HCAI surveillance and AMR data.

Prevention & Education

Seasonal influenza is an annual event. A safe vaccine is available, with an interim overall vaccine

efficacy (VE) estimate of 46% for those aged >65 years in the US 2016/17 season. VE depends on

match between vaccine and circulating influenza virus, with age and immune status also contributing

factors. (23, 24) Because of antigenic variance exhibited by the influenza virus, the vaccine must be

administered on an annual basis to optimise the match between vaccine and circulating influenza

types. The ideal time for vaccination is the autumn, prior to the anticipated onset of the annual

influenza season, to facilitate the recipient in mounting an optimal immune response prior to

potential exposure to the influenza virus. However, the vaccine may be administered at any time

during the influenza season and should be considered for any person in a category for which annual

seasonal influenza vaccine is recommended. National guidelines are available on the prevention and

management of influenza outbreaks in residential care facilities, with vaccination of residents and

healthcare workers key guideline recommendations. (25) Of the 224 LTCF participating in HALT 2016,

91% overall reported that annual seasonal influenza vaccine is offered to residents, a decline from

94% in 2013. However, an increase in participation by palliative care LTCF in 2016 may have

contributed to this. A survey of influenza vaccine uptake in residents of HSE-owned LTCF during the

2015-2016 influenza season reported that 87% of residents had been immunised against influenza

since the start of the season, an increase from 73% on the previous influenza season. (26)

Death is reported in 0.5 – 1.0 per 1000 cases of influenza. Research undertaken by the HPSC

estimates between 200 and 500 people in Ireland die each year from influenza-related illness. There

is a wealth of evidence that the elderly are at increased risk of both hospitalisation and death from

influenza infection. (27 – 29) During the 2015-16 influenza season in Ireland, 36 influenza outbreaks


Discussion 70

were notified, 21 of which were in LTCF. Of 84 deaths reported during the 2015-16 influenza season,

the median patient age was 65 years and four deaths were associated with influenza outbreaks. (30)

LTCF residents are likely to come into contact with influenza virus via infected healthcare workers

and visitors. The protective effect of the seasonal influenza vaccine is diminished in elderly or

immunocompromised patients. It is for these reasons that vaccination of healthcare workers is

recommended in Irish immunisation guidelines. (31) However, a survey of influenza vaccine uptake

in healthcare workers in 101 Irish LTCF during the 2015-16 influenza season, reported that just 26%

had availed of the opportunity to be vaccinated, an increase from 15% during the 2012-13 season.

(26) A systematic review of the effect of influenza vaccination of healthcare personnel on morbidity

and mortality among patients concluded that this intervention can enhance patient safety, as there

is evidence that it reduces the rate of hospitalisation and death due to influenza. (32) A Cochrane

review on influenza vaccination for healthcare staff caring for LTCF residents aged >60 years found

just five studies for inclusion and reported serious risks of methodological bias and very low quality

evidence arising from the included studies. The review highlighted the need for high quality

randomised control trials in this area. (44) Seasonal influenza vaccination should be offered to all

residents and staff of Irish LTCF, regardless of ownership, throughout the season, with up-to-date

records maintained of resident and staff immunisation status. It is imperative that staff have easy

access to vaccination in the workplace, through peer vaccinator programmes and that clear and

accurate information is provided to inform their decisions on vaccination. The percentage of

residents and staff immunised against influenza annually should be a KPI subject to regular review by

the senior management team of every LTCF and via the governance structures of regional HCAI &

AMR Committees.

In addition to annual seasonal influenza vaccination, LTCF residents should be assessed for

immunisation against Streptococcus pneumoniae and hepatitis B virus, where recommended by the

Immunisation Guidelines for Ireland. Up-to-date and accessible vaccination records should be

maintained for every resident.

Hand hygiene is an evidence-based intervention to prevent transmission of pathogenic

microorganisms and to prevent HCAI. The World Health Organisation (WHO) has published

Guidelines for Hand Hygiene in Healthcare and the WHO five moments for hand hygiene are the

basis for hand hygiene education programmes and audit of compliance. (46) ABHR is the preferred

method recommended by WHO for hand hygiene when hands are not visibly soiled. In 2016, 68% of

LTCF reported that ABHR was the preferred hand hygiene method, an improvement from 53% in

2013.


Discussion 71

Hand hygiene education and compliance audit are well-established in acute hospitals in Ireland, with

biannual acute hospital compliance audit results published on the HPSC website since 2011 and

training for lead hand hygiene auditors in acute hospitals coordinated by the HPSC. (47) While hand

hygiene training was reported to have been provided in the past year by 83% of LTCF in HALT 2016,

this was a reduction from 88% in 2013. Compliance audit of hand hygiene was reported to have

been carried out in the past year by 51% of LTCF. Further data on the protocol, methodology and

audit results was not captured by HALT 2016. It must be noted that hand hygiene compliance audit

protocols for acute hospitals are not automatically transferrable to LTCF settings and development

of national hand hygiene compliance audit protocols and tools specific to LTCF are required, with roll

out of lead hand hygiene auditor training and a train-the-trainer approach for hand hygiene audit, to

ensure that meaningful hand hygiene audits are conducted, using the same methodology and that

audit results are comparable across different CHOs.

The use of antimicrobials to prevent infection (prophylaxis) is not uncommon. However, the

evidence for this practice is limited, especially for the indications where it appears to be most

frequently used in LTCF. In 2016, UTI prevention accounted for 68% of prophylactic prescribing and

was particularly prevalent in Mixed>12m (3.4%), LTCF<12m (3.2%) and GN>12m (3.1%). However,

the prevalence of prophylaxis against RTI has increased from 2.3% (2010) to 2.9% (2016) and in 2016

was particularly prevalent in intellectually disabled (2%) and palliative care (1.5%) LTCF. It is

recommended that the indications for and duration of prophylaxis in these resident populations

should be further evaluated, in conjunction with any available evidence for such practices.

In 2011, national guidelines for the prevention of catheter-associated UTI were published by the

HPSC and after the publication of the 2011 HALT national report, the HALT steering group and

community antimicrobial stewardship committee developed a guideline for diagnosis and

management of UTI in long-term care residents >65 years, which states that antimicrobial

prophylaxis is not recommended for the prevention of symptomatic UTI in catheterised patients.

(33, 34) It is therefore of concern that 17% of residents prescribed UTI prophylaxis in 2016 were

reportedly catheterised (n=50 of 294).

The 2011 guideline also states that antimicrobial prophylaxis may be considered in patients for

whom the number of urinary infections are of such frequency or severity that they chronically

impinge on function and well‐being. (34) Guidance is also provided on signs and symptoms of UTI,

the indications for sending a urine specimen to the microbiology laboratory and on the

interpretation of culture results. Where residents are incontinent and disoriented, typical signs and

symptoms of recurrent UTI may be more difficult to elicit. Therefore, one might expect that it would


Discussion 72

be more difficult to justify the use of prophylaxis in such patients, particularly where diagnostic

uncertainty is commonplace (34)

LTCF staff education regarding the differences between asymptomatic bacteriuria and symptomatic

UTI is required. The presence of a positive urinary culture in the absence of urinary tract-specific

signs and symptoms may not equate to a UTI. It is possible that residents may have been mistakenly

labelled as suffering from recurrent UTIs, solely on the basis of repeated positive urine culture

results.

The HALT survey did not capture data regarding the duration of antimicrobial prescriptions.

However, it is recommended that a trial of urinary tract prophylaxis should not exceed six months.

The decision to prescribe prophylaxis should not be taken lightly and the resident must be fully

informed of the potential risks associated with antimicrobial exposure, particularly their increased

susceptibility to Clostridium difficile infection.

It is also important that any resident for whom nitrofurantoin is being prescribed for a prolonged

period is counselled about the potential serious complications of hepatic and pulmonary toxicity.

(37) In France, following a national drug monitoring alert issued in 2011, based on a frequency of

one case of severe hepatic or pulmonary toxicity per 7,666 nitrofurantoin prescriptions >1 month

duration, the French Agency for the Safety of Medicine and Health Products published guidelines

which recommended that nitrofurantoin must not be used for UTI prophylaxis. (38)

Those who prescribe and dispense antimicrobials must understand that when an antimicrobial is

prescribed for long-term prophylaxis, that agent may be lost as a future potential therapeutic agent,

owing to the development of AMR. The emergence and dissemination of ESBL-producing

Enterobacteriaceae in LTCF is a cause for concern. Nitrofurantoin is one of the very limited oral

antimicrobial options for treating uncomplicated UTI due to ESBL-producing E. coli and the loss of

this agent via uncontrolled prophylaxis further diminishes therapeutic options. Finally, indiscriminate

and prolonged courses of antimicrobial prophylaxis are costly both in economic terms and in

valuable nursing time, with regard to daily dispensing and administration.

There is evidence that the repeated HALT surveys and publication of the UTI guideline for LTCF have

had a positive impact on reducing prophylactic prescribing in Ireland. The overall prevalence

decreased from 4.3% to 3.8% between 2010 and 2013, but increased back to 4.3% in 2016. The UTI

prophylaxis prevalence decreased from 3.8% to 2.8% between 2010 and 2013, remaining stable at

2.9% in 2016. The fact that 43% of LTCF were first-time participants in HALT may have contributed to

the 2016 findings.


Discussion 73

Older age, immunocompromise and antimicrobial exposure are major risk factors for CDI. In HALT

2016, seven residents with CDI were reported, of whom four were deemed to have hospital-

acquired CDI. National guidelines for the surveillance, diagnosis and management of CDI were

updated in 2014 and it is recommended that they are also implemented by all Irish LTCF. (39)

Prospective surveillance and feedback of antimicrobial consumption is a key component of any

antimicrobial stewardship programme and it is recommended that this is advanced in each LTCF.

(40) Consumption surveillance could be reported for the overall LTCF, broken down further for

individual units/wards within the LTCF or for individual prescribers. Where the LTCF receives the

supply of prescription medication from an acute hospital pharmacy or a community pharmacy, a

summary report of antimicrobial consumption and expenditure by that LTCF should be requested on

a periodic basis (i.e., quarterly or biannually) by mutual agreement between the LTCF and pharmacy

management. The findings of each report should be formally discussed locally, fed back to medical

and nursing staff and trends monitored over time. With new developments in information

technology being utilised in general practice, GPs may also be able to obtain electronic summary

reports of their individual antimicrobial prescribing practices. The ability to further stratify

prescribing by patient/resident location and by indication should be sought. It is recommended that

the future provision of prescriber-level feedback to GPs on antimicrobial use be explored via existing

mechanisms, such as the Irish Primary Care Research Network.

As most GPs are self-employed and based within the community, it is important that they have easy

access to ongoing educational activities on HCAI prevention and management, AMR and

antimicrobial stewardship and that such educational activities are linked to continuing professional

development (CPD) credits, as part of the annual requirements of clinical professional competence

schemes. Educational materials should be available via a variety of routes, including e-learning,

publications and face-to-face educational workshops. The development of specific educational

‘toolkits’ for HCAI prevention and antimicrobial prescribing for use by trainee GPs and GPs should be

progressed, in conjunction with the ICGP.

LTCF residents and their families, friends and carers have an important role to play in the prevention

of HCAI and AMR in LTCF. Residents and their visitors should receive practical education on the

importance of social hand hygiene and be provided with easy access to hand hygiene products. It is

also recommended that educational materials, including information leaflets and access to on-line

resources be developed specifically for use by LTCF residents and their families, friends and carers,

with input from patient representative organisations. Information leaflets on hand hygiene,

influenza vaccination, prudent use of antibiotics and antibiotic resistant bacteria, such as MRSA,


Discussion 74

ESBLs, CRE and VRE should be developed for LTCF and displayed prominently within each LTCF. The

local HALT survey results and quality improvement plans within each LTCF should also be shared

with residents and their families.


References 75

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19. Patel G, Huprikar S, Factor SH, Jenkins SG, Calfee DP. Outcomes of carbapenem-resistant Klebsiella pneumoniae infection and the impact of antimicrobial and adjunctive therapies. Infect Control Hosp Epidemiol 2008 Dec; 29(12):1099-106.

20. Dhanji H, Doumith M, Rooney PJ, et al. Molecular epidemiology of fluoroquinolone-resistant ST131 Escherichia coli producing CTX-M extended-spectrum beta-lactamases in nursing homes in Belfast, UK. J Antimicrob Chemother 2011 Feb; 66(2):297-303.

21. Fennell J, Vellinga A, Hanahoe B, et al. Increasing prevalence of ESBL production among Irish clinical Enterobacteriaceae from 2004 to 2008: an observational study. BMC Infect Dis 2012; 12:116.

22. Pelly H, Morris D, O'Connell E, et al. Outbreak of extended spectrum beta-lactamase producing E. coli in a nursing home in Ireland, May 2006. Euro Surveill 2006; 11(8):E060831.

23. Flannery B, Chung JR, Thaker SN et al. Interim estimates of 2016-17 seasonal influenza vaccine effectiveness - United States, February 2017. Morb Mortal Wkly Rep 2017;66(6):167-171

24. Griffin MR. Influenza vaccination of healthcare workers: making the grade for action. Clin Infect Dis 2014 Jan; 58(1):58-60.

25. Public Health Medicine Communicable Disease Group. Public Health Guidelines on the Prevention and Management of Influenza Outbreaks in Residential Care Facilities in Ireland: 2016/2017. http://www.hpsc.ie/A-Z/Respiratory/Influenza/SeasonalInfluenza/Guidance/ResidentialCareFacilitiesGuidance/File,13195,en.pdf

26. Health Protection Surveillance Centre. Uptake of the Seasonal Influenza Vaccine in Acute Hospitals and Long-term Care Facilities in Ireland in 2015-2016 http://www.hpsc.ie/A-Z/Respiratory/Influenza/SeasonalInfluenza/InfluenzaandHealthcareWorkers/HCWInfluenzaVaccineUptakeReports/File,15542,en.pdf

27. Mazick A, Gergonne B, Nielsen J, et al. Excess mortality among the elderly in 12 European countries, February and March 2012. Euro Surveill 2012; 17(14).

28. Mertz D, Kim TH, Johnstone J, et al. Populations at risk for severe or complicated influenza illness: systematic review and meta-analysis. BMJ 2013; 347:f5061.

29. Nielsen J, Mazick A, Andrews N, et al. Pooling European all-cause mortality: methodology and findings for the seasons 2008/2009 to 2010/2011. Epidemiol Infect 2013 Sep; 141(9):1996-2010.

30. Health Protection Surveillance Centre. Annual Report of the Health Protection Surveillance Centre 2015. http://www.hpsc.ie/AboutHPSC/AnnualReports/

31. National Immunisation Advisory Committee. Immunisation Guidelines for Ireland - Chapter 11 - Influenza. (Updated September 2016) http://www.hse.ie/eng/health/immunisation/hcpinfo/guidelines/chapter11.pdf

https://www.hiqa.ie/reports-and-publications/standards/national-standards-residential-services-children-and-adults

https://www.hiqa.ie/reports-and-publications/standards/national-standards-residential-services-children-and-adults

http://www.hpsc.ie/A-Z/MicrobiologyAntimicrobialResistance/InfectionControlandHAI/Surveillance/HospitalPointPrevalenceSurveys/2012/PPS2012ReportsforIreland/



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34. Strategy for the Control of Antimicrobial Resistance in Ireland Working Group. Diagnosis and management of urinary tract infection in long-term care residents aged over 65 years (2011). http://www.hpsc.ie/A-Z/MicrobiologyAntimicrobialResistance/InfectionControlandHAI/Guidelines/File,12929,en.pdf

35. Mody L, Juthani-Mehta M. Urinary Tract Infections in Older Women. Journal of the American Medical Association 2014 Feb 26; 311(8):844-54.

36. Enzler MJ, Berbari E, Osmon DR. Antimicrobial prophylaxis in adults. Mayo Clin Proc 2011 Jul; 86(7):686-701.

37. Marshall AD, Dempsey OJ. Is "nitrofurantoin lung"on the increase? BMJ 2013; 346:f3897. 38. Slekovec C, Leroy J, Huttner A, et al. When the precautionary principle disrupts 3 years of

antibiotic stewardship: nitrofurantoin in the treatment of urinary tract infections. J Antimicrob Chemother 2014 Jan; 69(1):282-4.

39. National Clinical Effectiveness Committee. Surveillance, diagnosis and management of C. difficile infection in Ireland (2014) http://www.hpsc.ie/A-Z/MicrobiologyAntimicrobialResistance/InfectionControlandHAI/Guidelines/File,13950,en.pdf

40. Strategy for the Control of Antimicrobial Resistance in Ireland Working Group. Guidelines for Antimicrobial Stewardship in Hospitals in Ireland (2009) http://www.hpsc.ie/A-Z/MicrobiologyAntimicrobialResistance/InfectionControlandHAI/Guidelines/File,4116,en.pdf

41. Mental Health Commission Annual Report (2015) http://www.mhcirl.ie/Publications/Annual_Reports/

42. RCPI & HSE Clinical Advisory Group on HCAI & AMR. Guidelines for prevention and control of multi-drug resistant organisms, excluding MRSA in the healthcare setting (2013). http://www.hpsc.ie/A-Z/MicrobiologyAntimicrobialResistance/InfectionControlandHAI/Guidelines/File,12922,en.pdf

43. National Clinical Effectiveness Committee. Prevention and Control Methicillin Resistant Staphylococcus aureus (MRSA) (2013). http://www.hpsc.ie/A-Z/MicrobiologyAntimicrobialResistance/InfectionControlandHAI/Guidelines/File,14478,en.pdf

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Appendices 78

7. Appendices

Appendix A: List of HALT 2016 participating LTCF

HSE-owned LTCF

Name of Facility CHO Area Facility Type

St Mary's Hospital 1 GN > 12 months

Lisdarn Unit for Older Person 1 GN > 12 months

Virginia Services for Older Person 1 GN > 12 months

Breffni care Unit 1 GN > 12 months

Sullivan Centre 1 GN > 12 months

The Sheil Community Hospital 1 GN > 12 months

The Rock 1 GN > 12 months

Arus Breffni 1 GN > 12 months

St Patrick's Community Hospital 1 GN > 12 months

St John's Community Hospital 1 GN > 12 months

Tonnyglasson Disability Group Home 1 Intellectually disabled

Ros na Ri Disability Group Home 1 Intellectually disabled

Millbrook House 1 Intellectually disabled

Coill Aoibhinn 1 Intellectually disabled

Inbhear na Mara 1 Intellectually disabled

James Connolly Hospital 1 Intellectually disabled

Drogheda Ward, Sean O'Hare unit 1 Intellectually disabled

Cloonamahon Learning Disability Services 1 Intellectually disabled

Ard Greine Court, Sean O'Hare Unit & Associated Services 1 Intellectually disabled

Cregg House 1 Intellectually disabled

Piermount House, Dungloe 1 Intellectually disabled

Buncrana Community Hospital 1 LTCFs < 12 months

Carndonagh Community Hospital 1 LTCFs < 12 months

Donegal Community Hospital 1 LTCFs < 12 months

Falcarragh Community Hospital 1 LTCFs < 12 months

Killybegs Community Hospital 1 LTCFs < 12 months

Ard Aoibhinn Dementia Unit 1 LTCFs < 12 months


Appendices 79


St Joseph's Community Hospital 1 LTCFs < 12 months

Our Lady's Hospital Manorhamilton 1 LTCFs < 12 months

Dungloe Community Hospital 1 Mixed > 12 months

Ramelton Community Hospital 1 Mixed > 12 months

Arus Carolan 1 Mixed > 12 months

St Christopher’s Centre/Hospice 1 Other

Donegal Hospice 1 Palliative care

Blackwater House 1 Psychiatric

Park House 1 Psychiatric

Rowanfield House 1 Psychiatric

Sliabh na Rua SRU, Mental Health Services 1 Psychiatric

Aras Mhuire Community Nursing Unit 2 GN > 12 months

St Fionnan's Community Unit 2 Mixed > 12 months

An Coilin, Teach Aisling, St Anne's 2 Psychiatric

St Anne’s (Mayo Mental Health Services) 2 Psychiatric

Teach Aisling (Mayo Mental Health Services) 2 Psychiatric

St Conlon's Community Nursing Unit 3 GN > 12 months

St Ita's Hospital 3 GN > 12 months

Dean Maxwell Community Nursing Unit 3 Mixed > 12 months

Ennistymon Community Hospital 3 Mixed > 12 months

Raheen Community Hospital 3 Mixed > 12 months

St Joseph's Hospital Ennis 3 Mixed > 12 months

St Camillus' Hospital 3 Mixed > 12 months

Community Hospital of the Assumption 3 Mixed > 12 months

Cappahard Mental Health, Ennis, Co Clare 3 Psychiatric

O'Connell House 3 Psychiatric

St Camillus Hospital (Tearmann Ward) 3 Psychiatric

St Ita's Community Hospital - Rehabilitation Dept 3 Rehabilitation

St Finbarr's LTCF Douglas, Cork 4 GN > 12 months

Heather House Community Nursing Unit 4 GN > 12 months

Tralee Community Nursing Unit 4 GN > 12 months

Killarney Community Hospital LTCF 4 GN > 12 months

Castletownbere Community Hospital 4 GN > 12 months


Appendices 80


Dunmanway Community Hospital 4 GN > 12 months

Macroom Community Hospital 4 GN > 12 months

Millstreet Community Hospital 4 GN > 12 months

St Joseph's Residential Unit 4 GN > 12 months

Farranlea Road Community Nursing Unit - Care of the Elderly 4 GN > 12 months

St Raphael's Centre 4 Intellectually disabled

Cluainn Fhionnain Disability Services 4 Intellectually disabled

Killarney Community Hospital District 4 LTCFs < 12 months

Fermoy Community Hospital 4 LTCFs < 12 months

Listowel Community Hospital District ward 4 LTCFs < 12 months

Kinsale Community Hospital 4 Mixed > 12 months

Bandon Community Hospital 4 Mixed > 12 months

Mount Carmel Hospital 4 Mixed > 12 months

Caherciveen Community Hospital 4 Mixed > 12 months

Listowel Community Hospital 4 Mixed > 12 months

Midleton Community Hospital 4 Mixed > 12 months

Schull Community Hospital 4 Mixed > 12 months

West Kerry Community Hospital 4 Mixed > 12 months

Youghal Community Hospital 4 Mixed > 12 months

Kanturk Community Hospital 4 Mixed > 12 months

Cois Abhann Residential Facility 4 Other

Skibbereen Community Hospital 4 Other

Farranlea Road Community Nursing Unit - Cedar 4 Other

Mount Alvernia Hospital 4 Psychiatric

St Stephen's Hospital 4 Psychiatric

St Finbarr's Rehab Douglas Cork 4 Rehabilitation

St Columbas's Hospital 5 GN > 12 months

Kelvin Court, St Dympna's Hospital 5 Intellectually disabled

St Canice's Hospital (St Gabriel's Unit) 5 LTCFs < 12 months

Sacred Heart Hospital Carlow 5 Mixed > 12 months

Dungarvan Community Hospital 5 Mixed > 12 months

St Patrick's Hospital 5 Mixed > 12 months

Cluain Arann Community Nursing Unit 5 Mixed > 12 months


Appendices 81


Gorey District Hospital 5 Other

Carlow District Hospital 5 Other

Castlecomer District Hospital 5 Palliative care

Selskar Ward C/O Farnogue Unit 5 Psychiatric

Haywood Lodge, Clonmel 5 Psychiatric

St Ottermans Hospital - St Aidans Alzheimer unit 5 Psychiatric

St Otterman's Hospital - Grangemore Rehabilitation unit 5 Psychiatric

Baltinglass District Hospital 6 GN > 12 months

Belvilla 6 GN > 12 months

St Colman’s Residential Care Centre 6 GN > 12 months

Clonskeagh Community Nursing Unit 6 GN > 12 months

Newcastle Hospital - Avonmore 6 Psychiatric

Clonskeagh Hospital-Le Brun House and Whitethorn House 6 Psychiatric

St Vincent’s Hospital, Athy 7 GN > 12 months

Hospital 4 Residential Centre 7 GN > 12 months

Cherry Orchard Hospital Care of the Elderly 7 GN > 12 months

Meath Community Unit 7 GN > 12 months

Maynooth Community Care Unit 7 Mixed > 12 months

Cherry Orchard Hospital Young Chronically Ill 7 Other

Kildare West Wicklow Mental Health Services 7 Psychiatric

St Joseph’s Community Residential Nursing Unit 8 GN > 12 months

St Oliver Plunkett Hospital 8 GN > 12 months

Beaufort House 8 GN > 12 months

St Brigid's Hospital, Shaen Portlaoise 8 GN > 12 months

Birr Community Nursing Unit 8 GN > 12 months

Cluain Lír CNU 8 GN > 12 months

St Vincent's Centre 8 GN > 12 months

Riada House 8 LTCFs < 12 months

St Joseph's Care Centre 8 Mixed > 12 months

St Vincent’s Community Nursing Unit 8 Mixed > 12 months

St Joseph’s Hospital Ardee 8 Mixed > 12 months

An Solosan 8 Psychiatric

St Brigid's Hospital, St Ita's Ward 8 Psychiatric


Appendices 82


St Marys Hospital, Phoenix Park, Dublin 9 GN > 12 months

Raheny Community Nursing Unit 9 GN > 12 months

St Joseph’s Hospital IDS - Care of the Elderly 9 Intellectually disabled

Lusk Community Unit 9 Mixed > 12 months

St Clare's Nursing Home 9 Mixed > 12 months

Claremont Residential 9 Mixed > 12 months

St Mary's Phoenix Park Physically Disabled Ward 9 Physically Disabled

Fairview Community Rooms 9 Psychiatric

Phoenix Care Centre 9 Psychiatric

St Mary's Phoenix Park Rehab Ward 9 Rehabilitation

Private LTCF

Name of Facility CHO Area

Facility Type

St Eunan's Nursing Home 1 GN > 12 months

Oakview Nursing Home 1 GN > 12 months

Drumbear Nursing Home 1 GN > 12 months

Brindley Healthcare - Brentwood Manor 1 Mixed > 12 months

Abbeybreaffy Nursing Home 2 GN > 12 months

Aras Chois Fharraige 2 GN > 12 months

Holy Family Nursing Home 2 GN > 12 months

Rushmore Nursing Home 2 GN > 12 months

Tearmainn Bhride 2 GN > 12 months

Ballinderry Nursing Home 2 GN > 12 months

St Marys Residential Care Centre 2 GN > 12 months

Millrace Nursing Home 2 GN > 12 months

Cuan Chaitriona Nursing Home 2 GN > 12 months

Brindley Healthcare - Brookvale Manor 2 GN > 12 months

Rivervale Nursing Home 3 GN > 12 months

Kilrush Nursing Home 3 GN > 12 months

The Park Nursing Home 3 GN > 12 months

Milford Nursing Home 3 Mixed > 12 months

St Anthony’s Nursing Home 3 Mixed > 12 months


Appendices 83


Facility Type

St Michaels Nursing Home 3 Mixed > 12 months

Maryborough Nursing Home 4 GN > 12 months

Haven Bay Care Centre 4 GN > 12 months

Beaumont Residential Care 4 GN > 12 months

St Luke’s Home 4 GN > 12 months

Cuil Didin 4 GN > 12 months

Norwood Grange 4 GN > 12 months

Glyntown Care Centre 4 Mixed > 12 months

Greenhill Nursing Home 5 GN > 12 months

Strathmore Lodge Nursing Home 5 GN > 12 months

Drakelands House Nursing Home 5 Mixed > 12 months

Knockeen Nursing Home 5 Mixed > 12 months

Cairnhill Nursing Home 6 GN > 12 months

Aclare House Nursing Home 6 GN > 12 months

Carysfort Nursing Home 6 GN > 12 months

Orwell House Nursing Home 6 Mixed > 12 months

Marymount Care Centre 7 GN > 12 months

TLC Centre Maynooth 7 GN > 12 months

Glenaulin Nursing Home 7 GN > 12 months

Parke House Nursing Home 7 Mixed > 12 months

Esker Ri 8 GN > 12 months

Woodlands House 8 GN > 12 months

Newbrook Group - Portiuncula Nursing Home 8 GN > 12 months

Sunhill Nursing Home 8 GN > 12 months

Kilbrew Recuperation and Nursing Care 8 GN > 12 months

Our Lady's Manor 8 GN > 12 months

Newbrook Nursing Home 8 GN > 12 months

Oakdale Nursing Home 8 LTCFs < 12 months

Sonas Nursing Home, Athlone 8 Mixed > 12 months

La Verna Nursing Home 9 GN > 12 months

Riverside Nursing Home 9 GN > 12 months

Cara Care Centre 9 GN > 12 months

Elm Green Nursing Home 9 Mixed > 12 months


Appendices 84


Facility Type

Swords Nursing 9 Mixed > 12 months

Tara Winthrop Private Clinic 9 Mixed > 12 months

Voluntary LTCF


Facility Type

Galway Hospice Foundation 2 Palliative care

Daughter of Charity, St Vincent's Centre 3 Intellectually disabled

Milford Care Centre (Hospice) 3 Palliative care

Our Lady of Fatima Home 4 GN > 12 months

Cope Foundation 4 Intellectually disabled

Cope Foundation Riverview Retirement Home 4 Intellectually disabled

Cope Foundation Teach Cairde 4 Intellectually disabled

St Mary of the Angels - Campus area 4 Intellectually disabled

Brothers of Charity St Patrick's Hospital 4 Intellectually disabled

Kerry Parents and Friends Association - Gleeb 4 Intellectually disabled

Cope Foundation - Glasheen 4 Intellectually disabled

Gowran Abbey Nursing Home 5 GN > 12 months

Leopardstown Park Hospital 6 GN > 12 months

St Marys Home Ballsbridge 6 GN > 12 months

Our Lady's Manor Dalkey 6 GN > 12 months

St Marys Centre Telford Ltd 6 Mixed > 12 months

St Joseph's Centre, Crinken Lane 6 Other

Caritas Convalescent Centre 6 Other

Peamount Long-term Care 7 GN > 12 months

Peamount Intellectual Disability 7 Intellectually disabled

St Louise's Centre 7 Intellectually disabled

Stewarts Care 7 Intellectually disabled

Cheeverstown House DC1, 2, 3 & 4 7 Intellectually disabled

Our Lady's Hospice & Care Services - Extended care unit 7 Mixed > 12 months

Harold's Cross Palliative Care Unit 7 Palliative care

Harold's Cross Rehab Unit 7 Rehabilitation

Peamount Rehabilitation 7 Rehabilitation


Appendices 85


Facility Type

Santa Sabina House 9 GN > 12 months

St Michael's House LTCF 9 Intellectually disabled

St Vincent's Centre 9 Intellectually disabled

St Michael's House Extra 1 9 Intellectually disabled

St Michael's House Extra 2 9 Intellectually disabled

St Francis' Hospice Raheny 9 Palliative care

St Francis Hospice Blanchardstown 9 Palliative care

HSE-owned LTCF, stratified by CHO and by care type

Facility Type CHO 1 CHO 2 CHO 3 CHO 4 CHO 5 CHO 6 CHO 7 CHO 8 CHO 9

GN > 12 months 10 1 2 10 1 4 4 7 2

Mixed > 12 months 3 1 6 10 4 0 1 3 3

LTCFs < 12 months 8 0 0 3 1 0 0 1 0

Intellectually

disabled11 0 0 2 1 0 0 0 1

Palliative care 1 0 0 0 1 0 0 0 0

Psychiatric 4 3 3 2 4 2 1 2 2

Physically Disabled 0 0 0 0 0 0 0 0 1

Rehabilitation 0 0 1 1 0 0 0 0 1

Other 1 0 0 3 2 0 1 0 0


Appendices 86

Appendix B: HALT 2016 National Steering Group Membership

Dr Karen Burns, Consultant Microbiologist, HSE-HPSC & Beaumont Hospital (Chair)

Ms Helen Murphy, Infection Prevention & Control Nurse Manager, HSE-HPSC

Ms Margaret Nadin, Project Manager, HSE NMPDU, Dublin-North East

Ms Mary McKenna, Lead Infection Prevention & Control ADON, HSE HCAI & AMR Clinical

Programme, Quality Improvement Division

Ms Grainne Parker, Communicable Disease Control Nurse, Public Health Department, HSE

South (South East)

Ms Mags Moran, Community Infection Control Nurse Manager, Donegal Community

Services, HSE West

Dr Nuala O’Connor, General Practitioner & ICGP Lead HSE HCAI & AMR Clinical Programme,

Quality Improvement Division

Dr Diarmuid O’Shea, Consultant Geriatrician, St Vincent’s University Hospital & HSE Clinical

Programme for Older People, Clinical Lead

Dr Mimi Fan, Consultant Geriatrician, Mater Hospital, Irish Society for Physicians in Geriatric

Medicine

Ms Fiona McMahon, Project Manager, HSE NMPDU Mid-West/ONMSD

Mr Gerry Clerkin, Head of Quality & Safety, HSE Social Care Division

Ms Linda Moore, Quality, Standards & Compliance Officer, HSE National Mental Health

Division

Ms Lisa Malone, Practice Development Facilitator, Nursing Homes Ireland

Dr Fidelma Fitzpatrick, Consultant Microbiologist, Beaumont Hospital & Senior Lecturer in

Microbiology, RCSI

Dr Fiona Roche, Trinity College Dublin, Bioinformatics Support Research Fellow

Dr Ian Callanan, Group Clinical Audit Facilitator, St Vincent’s Healthcare Group

Dr Akke Vellinga, Senior Lecturer & Epidemiologist, School of Medicine, NUI Galway

Ms Sheila Donlon, ADON Infection Prevention & Control Department, Beaumont Hospital

Mr Sean Egan, Regulatory Lead for Antimicrobial Stewardship, Health Information & Quality

Authority

Ms Meera Tandan, PhD student, NUI Galway

Ms Rita Torrans, Community Pharmacist, Abbey Healthcare, Irish Pharmaceutical Union

Ms Josephine Galway, Director of Nursing, St Columba’s Hospital & Castlecomer District

Hospital, Irish Association of Directors of Nursing & Midwifery

The HALT 2016 Steering Group has been convened under the auspices of the Royal College of

Physicians of Ireland & Health Service Executive Clinical Advisory Group on Healthcare-Associated

Infections & Antimicrobial Resistance


Appendices 87

Appendix C: Acronyms used in this Report

ABHR Alcohol-Based Hand Rub

AMR Antimicrobial Resistance

ASC Antimicrobial Stewardship Committee

CDC US Centers for Disease Control & Prevention

CDI Clostridium difficile infection

CHO Community Healthcare Organisation

CPD Continuing Professional Development

CRE Carbapenem resistant Enterobacteriaceae

ECDC European Centre for Disease Prevention and Control

ESBL Extended Spectrum Beta Lactamase

FAQ Frequently-Asked Questions

GN>12m General nursing homes with LOS > 12 months

GP General Practitioner

HAI Hospital-acquired Infection

HALT Healthcare-Associated Infections in Long-Term Care Facilities

HCA Healthcare Assistant

HCAI Healthcare-Associated Infection

HIQA Health Information & Quality Authority

HPSC Health Protection Surveillance Centre

HSE Health Service Executive

ICGP Irish College of General Practitioners


Appendices 88

IPC Infection Prevention & Control

IPCC Infection Prevention & Control Committee

IPCN Infection Prevention & Control Nurse

KPI Key Performance Indicator

LAI Long-Term Care Facility-Acquired Infection

LOS Length-of-Stay

LTCF Long-Term Care Facility/Facilities

LTCF<12m LTCF (either general nursing home or mixed care type) with LOS < 12 months

MDR Multi-drug resistant

MDRKP MDR Klebsiella pneumoniae

MHC Mental Health Commission

Mixed>12m Mixed care facilities with LOS > 12 months

MRSA Meticillin Resistant Staphylococcus aureus

MSSA Meticillin Susceptible Staphylococcus aureus

MDRO Multi-Drug Resistant Organisms

PPE Personal Protective Equipment

PPS Point Prevalence Survey

RCPI Royal College of Physicians of Ireland

RTI Respiratory Tract Infection

SHEA Society for Healthcare Epidemiology of America

SSI Surgical Site Infection

UTI Urinary Tract Infection

VE Vaccine Efficacy


Appendices 89

VRE Vancomycin Resistant Enterococci

WHO World Health Organisation

WIV-ISP Scientific Institute for Public Health, Brussels, Belgium

WTE Whole Time Equivalent

3GC 3rd Generation Cephalosporins


Appendices 90

Appendix D: HALT Resident Questionnaire & HCAI definitions http://www.hpsc.ie/A-Z/MicrobiologyAntimicrobialResistance/InfectionControlandHAI/Surveillance/HCAIinlongtermcarefacilities/DocumentationandsoftwareforundertakingHALT/File,15619,en.pdf

http://www.hpsc.ie/A-Z/MicrobiologyAntimicrobialResistance/InfectionControlandHAI/Surveillance/HCAIinlongtermcarefacilities/DocumentationandsoftwareforundertakingHALT/File,15619,en.pdf


Appendices 91


Appendices 92


Appendices 93


Appendices 94

Appendix E: Community Healthcare Organisations (CHO) Map of Ireland

Documents

Point Prevalence Survey of Healthcare-Associated ... · trained IPC staff member, that person was an infection prevention and control nurse (IPCN) (93.5%). However, for the majority